Provider Demographics
NPI:1790922979
Name:PINE HILL HOME SUPPORTS,INC.
Entity Type:Organization
Organization Name:PINE HILL HOME SUPPORTS,INC.
Other - Org Name:RUSHES FOSTER HOMES
Other - Org Type:Other Name
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-933-2915
Mailing Address - Street 1:198 PINE HILL RD.
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04259
Mailing Address - Country:US
Mailing Address - Phone:207-933-2915
Mailing Address - Fax:207-933-9122
Practice Address - Street 1:198 PINE HILL RD
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04259-7517
Practice Address - Country:US
Practice Address - Phone:207-933-2915
Practice Address - Fax:207-933-9122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS 3061320900000X
MEALLS 2371320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME125520000Medicaid
ME125520001Medicaid