Provider Demographics
NPI:1184852022
Name:BERNADETTE FORTIN
Entity type:Organization
Organization Name:BERNADETTE FORTIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FORTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-868-9853
Mailing Address - Street 1:144 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:ME
Mailing Address - Zip Code:04785
Mailing Address - Country:US
Mailing Address - Phone:207-868-9853
Mailing Address - Fax:
Practice Address - Street 1:144 HIGH ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:ME
Practice Address - Zip Code:04785
Practice Address - Country:US
Practice Address - Phone:207-868-9853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME217680000Medicaid