MEDICARE: PALMS RESIDENTIAL CARE

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1265033088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMS RESIDENTIAL CARE

Provider Business Mailing Address
First Line	:	1500 FOREST AVE APT 13D
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04103-1846
Country	:	US
Telephone Number	:	978-620-8376
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 FOREST AVE APT 13D
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04103-1846
Country	:	US
Telephone Number	:	978-620-8376
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	PATRICK KIFOKIE MULONDA
Credential	:
Telephone Number	:	978-620-8376

Provider Enumeration Date	:	11/06/2020
Last Update Date	:	11/06/2020

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