Provider Demographics
NPI:1578713897
Name:PREBLE STREET RESOURCE CENTER - LOGAN PLACE
Entity Type:Organization
Organization Name:PREBLE STREET RESOURCE CENTER - LOGAN PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-775-0026
Mailing Address - Street 1:P.O. BOX 1459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104
Mailing Address - Country:US
Mailing Address - Phone:207-775-0026
Mailing Address - Fax:207-842-3614
Practice Address - Street 1:52 FREDRIC STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04104
Practice Address - Country:US
Practice Address - Phone:207-775-0026
Practice Address - Fax:207-842-3614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431576201Medicaid