Provider Demographics
NPI:1255362943
Name:CENTERWELL CERTIFIED HEALTHCARE CORP.
Entity type:Organization
Organization Name:CENTERWELL CERTIFIED HEALTHCARE CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNATORY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-772-0954
Mailing Address - Street 1:6330 SPRINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 ATLANTIC PL
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2316
Practice Address - Country:US
Practice Address - Phone:207-772-0954
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME160770000Medicaid
ME160770200Medicaid
000000015681OtherG2
ME160770202Medicaid
ME160770003Medicaid
2273784OtherG2
60-03419OtherG2
013100POtherG2
120243OtherG2
235397OtherG2
702022OtherG2
ME160770100Medicaid
207038OtherG2
565800OtherG2
7706020OtherG2
801438OtherG2
17029OtherG2
7706020OtherG2
ME160770200Medicaid
ME160770202Medicaid