Provider Demographics
NPI:1578753836
Name:JADE TRADE INC.
Entity Type:Organization
Organization Name:JADE TRADE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LATENDRESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-773-5778
Mailing Address - Street 1:218 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2632
Mailing Address - Country:US
Mailing Address - Phone:207-773-5778
Mailing Address - Fax:207-773-5773
Practice Address - Street 1:218 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2632
Practice Address - Country:US
Practice Address - Phone:207-773-5778
Practice Address - Fax:207-773-5773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC200171100000X
PT2432225100000X
MEMT1458225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0003037Medicare PIN