Provider Demographics
NPI:1497969794
Name:BREMEN
Entity Type:Organization
Organization Name:BREMEN
Other - Org Name:AOS 93
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF SPECIAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:DERYL
Authorized Official - Middle Name:C
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-563-3044
Mailing Address - Street 1:767 MAIN STREET, 1A
Mailing Address - Street 2:
Mailing Address - City:DAMARISCOTTA
Mailing Address - State:ME
Mailing Address - Zip Code:04543
Mailing Address - Country:US
Mailing Address - Phone:207-563-3044
Mailing Address - Fax:
Practice Address - Street 1:767 MAIN STREET, 1A
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543
Practice Address - Country:US
Practice Address - Phone:207-563-3044
Practice Address - Fax:207-563-8276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME136200000Medicaid