Provider Demographics
NPI:1508524638
Name:200 YEARS OLD, LLC
Entity Type:Organization
Organization Name:200 YEARS OLD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:MR
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:
Authorized Official - Last Name:HABIMFURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-518-0881
Mailing Address - Street 1:5 BLACKSTRAP RD
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-2223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 BLACKSTRAP RD
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-2223
Practice Address - Country:US
Practice Address - Phone:207-518-0881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-06
Last Update Date:2023-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care