Provider Demographics
NPI:1932184900
Name:ADVANCE
Entity Type:Organization
Organization Name:ADVANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:207-786-0168
Mailing Address - Street 1:265 PINE ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-6308
Mailing Address - Country:US
Mailing Address - Phone:207-786-0168
Mailing Address - Fax:
Practice Address - Street 1:265 PINE ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6308
Practice Address - Country:US
Practice Address - Phone:207-786-0168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME202650000Medicaid