Provider Demographics
NPI:1558351841
Name:SEAPORT VILLAGE SKILLED NURSING CENTER LLC
Entity Type:Organization
Organization Name:SEAPORT VILLAGE SKILLED NURSING CENTER LLC
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:
Authorized Official - Phone:207-874-2700
Mailing Address - Street 1:19 GENERAL MOORE WAY
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-1806
Mailing Address - Country:US
Mailing Address - Phone:207-667-9336
Mailing Address - Fax:
Practice Address - Street 1:19 GENERAL MOORE WAY
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1806
Practice Address - Country:US
Practice Address - Phone:207-667-9336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36346235Z00000X, 261QP2000X, 261QX0100X
ME36555314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME104690000Medicaid
ME104690000Medicaid