Provider Demographics
NPI: | 1497997233 |
---|---|
Name: | FREEPORT PLACE |
Entity Type: | Organization |
Organization Name: | FREEPORT PLACE |
Other - Org Name: | |
Other - Org Type: | |
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: | CEO |
Authorized Official - Phone: | 207-874-2700 |
Mailing Address - Street 1: | 4 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: | 207-865-3500 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 4 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: | 207-865-3500 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-03-25 |
Last Update Date: | 2009-03-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
ME | 2103 | 310400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
ME | 2103 | Medicaid |