Provider Demographics
NPI:1528201738
Name:SEVENTY FIVE STATE STREET
Entity Type:Organization
Organization Name:SEVENTY FIVE STATE STREET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORGIONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-772-2675
Mailing Address - Street 1:75 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3746
Mailing Address - Country:US
Mailing Address - Phone:207-772-2675
Mailing Address - Fax:207-772-2896
Practice Address - Street 1:75 STATE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3746
Practice Address - Country:US
Practice Address - Phone:207-772-2675
Practice Address - Fax:207-772-2896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-17
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS2085310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME101970000Medicaid