Provider Demographics
NPI:1295961647
Name:SOUTHERN MAINE AGENCY ON AGING
Entity type:Organization
Organization Name:SOUTHERN MAINE AGENCY ON AGING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-396-6505
Mailing Address - Street 1:136 US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9055
Mailing Address - Country:US
Mailing Address - Phone:207-396-6500
Mailing Address - Fax:207-883-8249
Practice Address - Street 1:30 BARRA RD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9459
Practice Address - Country:US
Practice Address - Phone:207-283-0166
Practice Address - Fax:207-282-2470
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN MAINE AGENCY ON AGING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-29
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
MEALLS3017261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MELAR003-AOtherEIM
MESOU003-AOtherEIM
MEVA402(241)-P-0011OtherVA
ME109570100Medicaid