Provider Demographics
NPI:1891832382
Name:NANCY J. MITCHELL HOME TRUST
Entity Type:Organization
Organization Name:NANCY J. MITCHELL HOME TRUST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRUSTEE
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-827-6688
Mailing Address - Street 1:PO BOX 1381
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 SANDY BEACH LANE
Practice Address - Street 2:
Practice Address - City:INDIAN ISLAND
Practice Address - State:ME
Practice Address - Zip Code:04468
Practice Address - Country:US
Practice Address - Phone:207-827-6688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME126500000320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME53161131AMedicaid
ME53161131AMedicaid