Provider Demographics
NPI:1467446393
Name:ROUSSEAU ENTERPRISES, INC.
Entity Type:Organization
Organization Name:ROUSSEAU ENTERPRISES, INC.
Other - Org Name:AMENITY MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-725-4071
Mailing Address - Street 1:29 ELM ST
Mailing Address - Street 2:
Mailing Address - City:TOPSHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04086-1423
Mailing Address - Country:US
Mailing Address - Phone:207-725-7495
Mailing Address - Fax:207-725-7195
Practice Address - Street 1:29 ELM ST
Practice Address - Street 2:
Practice Address - City:TOPSHAM
Practice Address - State:ME
Practice Address - Zip Code:04086-1423
Practice Address - Country:US
Practice Address - Phone:207-725-7495
Practice Address - Fax:207-725-7195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME35865313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME111890001Medicaid
ME0700370001Medicare NSC
ME20 5085Medicare Oscar/Certification