Provider Demographics
NPI:1225124050
Name:HOULTON BAND OF MALISEET INDIANS
Entity Type:Organization
Organization Name:HOULTON BAND OF MALISEET INDIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGE
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALM
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:207-532-4229
Mailing Address - Street 1:88 BELL RD STE 2
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:ME
Mailing Address - Zip Code:04730-6704
Mailing Address - Country:US
Mailing Address - Phone:207-532-4229
Mailing Address - Fax:
Practice Address - Street 1:12 CLOVER CIRCLE
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730
Practice Address - Country:US
Practice Address - Phone:207-532-4229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001175OtherANTHEM IDENTIFIER
MEMM7432Medicare ID - Type Unspecified