Provider Demographics
NPI:1225022163
Name:ROUSSEAU ENTERPRISES LLC
Entity Type:Organization
Organization Name:ROUSSEAU ENTERPRISES LLC
Other - Org Name:MONTELLO MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-874-2700
Mailing Address - Street 1:540 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5228
Mailing Address - Country:US
Mailing Address - Phone:207-783-2039
Mailing Address - Fax:207-782-0184
Practice Address - Street 1:540 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5228
Practice Address - Country:US
Practice Address - Phone:207-783-2039
Practice Address - Fax:207-782-0184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1787313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME111890002Medicaid
ME0700370002Medicare NSC
ME111890002Medicaid