Provider Demographics
NPI:1407970577
Name:KIDSPEACE NATIONAL CENTERS OF NEW ENGLAND INC
Entity Type:Organization
Organization Name:KIDSPEACE NATIONAL CENTERS OF NEW ENGLAND INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FOR MARKETING AND BUSINESS DEVEL
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-854-3123
Mailing Address - Street 1:4085 INDEPENDENCE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SCHENECKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18078
Mailing Address - Country:US
Mailing Address - Phone:800-854-3123
Mailing Address - Fax:610-799-8318
Practice Address - Street 1:747 WESTERN AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:MANCHESTER
Practice Address - State:ME
Practice Address - Zip Code:04351-3528
Practice Address - Country:US
Practice Address - Phone:207-622-1404
Practice Address - Fax:207-623-7637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME322081251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432233203Medicaid