Provider Demographics
NPI:1003239179
Name:MARKET SQUARE HEALTH CARE CENTER, LLC
Entity type:Organization
Organization Name:MARKET SQUARE HEALTH CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:CYR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-786-3554
Mailing Address - Street 1:179 LISBON ST STE 2
Mailing Address - Street 2:P.O. BOX 1408
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7248
Mailing Address - Country:US
Mailing Address - Phone:207-786-3554
Mailing Address - Fax:207-786-8507
Practice Address - Street 1:3 MARKET SQ
Practice Address - Street 2:
Practice Address - City:SOUTH PARIS
Practice Address - State:ME
Practice Address - Zip Code:04281-1114
Practice Address - Country:US
Practice Address - Phone:207-743-7086
Practice Address - Fax:207-743-2395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2625314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
205076Medicare PIN