Provider Demographics
NPI:1730314824
Name:MAIN STREAM HOME
Entity Type:Organization
Organization Name:MAIN STREAM HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-683-2016
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:HARMONY
Mailing Address - State:ME
Mailing Address - Zip Code:04942-0008
Mailing Address - Country:US
Mailing Address - Phone:207-683-2016
Mailing Address - Fax:
Practice Address - Street 1:248 CAMBRIDGE RD
Practice Address - Street 2:
Practice Address - City:HARMONY
Practice Address - State:ME
Practice Address - Zip Code:04942-0008
Practice Address - Country:US
Practice Address - Phone:207-683-2016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS 3065320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME215920000Medicaid