Provider Demographics
NPI:1619114634
Name:SPRUCE RUN - TH PROGRAM
Entity Type:Organization
Organization Name:SPRUCE RUN - TH PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GRANTS
Authorized Official - Prefix:
Authorized Official - First Name:DORATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-945-5102
Mailing Address - Street 1:P.O. BOX 653
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0653
Mailing Address - Country:US
Mailing Address - Phone:207-945-5102
Mailing Address - Fax:207-990-4252
Practice Address - Street 1:77 ESSEX
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04402
Practice Address - Country:US
Practice Address - Phone:207-945-5102
Practice Address - Fax:207-990-4252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432212700Medicaid