MEDICARE: KATAHDIN VALLEY HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1053063107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KATAHDIN VALLEY HEALTH CENTER

Provider Business Mailing Address
First Line	:	529 S PATTEN RD
Second Line	:
City	:	PATTEN
State	:	ME
Zip	:	04765-3007
Country	:	US
Telephone Number	:	207-528-2285
Fax Number	:	207-528-2880

Provider Business Practice Location Address
First Line	:	48 E MAIN ST
Second Line	:
City	:	DOVER FOXCROFT
State	:	ME
Zip	:	04426-1323
Country	:	US
Telephone Number	:	207-528-2285
Fax Number	:	207-528-2280

Authorized Official
Title or Position	:	CEO
Name	:	CLAUDETTE G HUMPHREY
Credential	:
Telephone Number	:	207-528-2285

Provider Enumeration Date	:	01/20/2022
Last Update Date	:	03/12/2022

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