Provider Demographics
NPI:1427026657
Name:FREEPORT CONVALESCENT CENTER INC
Entity Type:Organization
Organization Name:FREEPORT CONVALESCENT CENTER INC
Other - Org Name:HAWTHORNE HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
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 1:6 OLD COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6231
Mailing Address - Country:US
Mailing Address - Phone:207-865-4782
Mailing Address - Fax:207-865-1308
Practice Address - Street 1:6 OLD COUNTY RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6231
Practice Address - Country:US
Practice Address - Phone:207-865-4782
Practice Address - Fax:207-865-1308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2005235Z00000X, 261QP2000X, 261QX0100X, 314000000X
ME2103310400000X, 310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Single Specialty
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME120030000Medicaid
ME120030001Medicaid
ME115110000Medicaid
ME115110000Medicaid