Provider Demographics
NPI:1467902668
Name:FISH RIVER RURAL HEALTH
Entity Type:Organization
Organization Name:FISH RIVER RURAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:PELLETIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-444-5973
Mailing Address - Street 1:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:ME
Mailing Address - Zip Code:04739-0309
Mailing Address - Country:US
Mailing Address - Phone:207-728-4779
Mailing Address - Fax:
Practice Address - Street 1:309 SAINT THOMAS ST
Practice Address - Street 2:
Practice Address - City:MADAWASKA
Practice Address - State:ME
Practice Address - Zip Code:04756-1278
Practice Address - Country:US
Practice Address - Phone:207-728-4779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME7582380001Medicare NSC