Provider Demographics
NPI:1356960728
Name:KALEIDOSCOPE EATING DISORDERS AND DIET RECOVERY CENTER
Entity type:Organization
Organization Name:KALEIDOSCOPE EATING DISORDERS AND DIET RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:207-205-5505
Mailing Address - Street 1:75 MARKET ST STE 304
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-5040
Mailing Address - Country:US
Mailing Address - Phone:207-205-5505
Mailing Address - Fax:
Practice Address - Street 1:75 MARKET ST STE 304
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-5040
Practice Address - Country:US
Practice Address - Phone:207-205-5505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service