Provider Demographics
NPI:1790776110
Name:ST JOSEPHS REHABILITATION & RESIDENCE
Entity Type:Organization
Organization Name:ST JOSEPHS REHABILITATION & RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-797-0600
Mailing Address - Street 1:1133 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3629
Mailing Address - Country:US
Mailing Address - Phone:207-797-0600
Mailing Address - Fax:207-797-4168
Practice Address - Street 1:1133 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3629
Practice Address - Country:US
Practice Address - Phone:207-797-0600
Practice Address - Fax:207-797-4168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1908310400000X, 313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME107380000Medicaid
ME107380001Medicaid
ME107380000Medicaid