Provider Demographics
NPI:1417280306
Name:ODD FELLOWS & REBEKAHS HOME OF MAINE
Entity Type:Organization
Organization Name:ODD FELLOWS & REBEKAHS HOME OF MAINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERNIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-786-4616
Mailing Address - Street 1:85 CARON LN
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-4288
Mailing Address - Country:US
Mailing Address - Phone:207-786-4616
Mailing Address - Fax:207-786-4064
Practice Address - Street 1:85 CARON LANE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210
Practice Address - Country:US
Practice Address - Phone:207-786-4616
Practice Address - Fax:207-786-4064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2329310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME102150001Medicaid