Provider Demographics
NPI:1659486884
Name:BANGOR INTEGRATIVE HEALTH
Entity type:Organization
Organization Name:BANGOR INTEGRATIVE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LEONA
Authorized Official - Middle Name:
Authorized Official - Last Name:CERKOVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:207-866-9025
Mailing Address - Street 1:192 PARK ST
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04473-4602
Mailing Address - Country:US
Mailing Address - Phone:207-866-9025
Mailing Address - Fax:207-866-2207
Practice Address - Street 1:192 PARK ST
Practice Address - Street 2:
Practice Address - City:ORONO
Practice Address - State:ME
Practice Address - Zip Code:04473-4602
Practice Address - Country:US
Practice Address - Phone:207-866-9025
Practice Address - Fax:207-866-2207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME038985163WP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MENG0101Medicare ID - Type Unspecified