Provider Demographics
NPI:1841079407
Name:OPEN DOOR WELLNESS LLC,
Entity type:Organization
Organization Name:OPEN DOOR WELLNESS LLC,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DOLORES
Authorized Official - Middle Name:IMELDA
Authorized Official - Last Name:VAN BOURGONDIEN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:207-200-7518
Mailing Address - Street 1:375 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04841-3304
Mailing Address - Country:US
Mailing Address - Phone:561-866-1211
Mailing Address - Fax:
Practice Address - Street 1:375 MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKLAND
Practice Address - State:ME
Practice Address - Zip Code:04841-3304
Practice Address - Country:US
Practice Address - Phone:561-866-1211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty