Provider Demographics
NPI:1801030986
Name:PIERCE RESIDENTIAL CARE
Entity Type:Organization
Organization Name:PIERCE RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOSTER HOME PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:E
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:207-843-0724
Mailing Address - Street 1:PO BOX 314
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04429
Mailing Address - Country:US
Mailing Address - Phone:207-843-0724
Mailing Address - Fax:
Practice Address - Street 1:24 ROCK RIDGE RD
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:ME
Practice Address - Zip Code:04429
Practice Address - Country:US
Practice Address - Phone:207-843-0724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS 3008320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1D 208240000Medicaid