Provider Demographics
NPI:1477797181
Name:FAIRMOUNT BOARDING HOME
Entity Type:Organization
Organization Name:FAIRMOUNT BOARDING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:H
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-924-6211
Mailing Address - Street 1:8 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4538
Mailing Address - Country:US
Mailing Address - Phone:207-942-5816
Mailing Address - Fax:207-942-2701
Practice Address - Street 1:8 13TH ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4538
Practice Address - Country:US
Practice Address - Phone:207-942-5816
Practice Address - Fax:207-942-2701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RAYMOND H BISHOP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-24
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS 3363311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME103580001Medicaid