Provider Demographics
NPI:1508100124
Name:WINDHAM RESIDENTIAL CARE FACILITY, INC
Entity Type:Organization
Organization Name:WINDHAM RESIDENTIAL CARE FACILITY, INC
Other - Org Name:REST-A-VILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-892-7141
Mailing Address - Street 1:495 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-4603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:497 RIVER RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-4603
Practice Address - Country:US
Practice Address - Phone:207-892-7141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities