Provider Demographics
NPI:1265643670
Name:NORTHERN MAINE GENERAL
Entity Type:Organization
Organization Name:NORTHERN MAINE GENERAL
Other - Org Name:DEVOE BROOK WAIVER HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:REYNOLD
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-444-5152
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:ME
Mailing Address - Zip Code:04739-0310
Mailing Address - Country:US
Mailing Address - Phone:207-444-5152
Mailing Address - Fax:207-444-6099
Practice Address - Street 1:39 DEVOE BROOK RD
Practice Address - Street 2:
Practice Address - City:EAGLE LAKE
Practice Address - State:ME
Practice Address - Zip Code:04739-0310
Practice Address - Country:US
Practice Address - Phone:207-444-5152
Practice Address - Fax:207-444-6099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS 2222320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities