MEDICARE: STATE OF MAINE HEALTH AND ENVIRONMENTAL TESSTING LABORATORY

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	291U00000X	Clinical Medical Laboratory		ME

General Provider Information

NPI Number	:	1407985302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF MAINE HEALTH AND ENVIRONMENTAL TESSTING LABORATORY

Provider Business Mailing Address
First Line	:	STATION 12
Second Line	:	221 STATE STREET
City	:	AUGUSTA
State	:	ME
Zip	:	04333-0001
Country	:	US
Telephone Number	:	207-287-2703
Fax Number	:

Provider Business Practice Location Address
First Line	:	STATION 12
Second Line	:	221 STATE STREET
City	:	AUGUSTA
State	:	ME
Zip	:	04333-0001
Country	:	US
Telephone Number	:	207-287-2703
Fax Number	:

Authorized Official
Title or Position	:	SENIOR SCIENTIST CLIA LAB DIRECTOR
Name	:	DR. KENNETH G. POTE
Credential	:	PH.D.
Telephone Number	:	207-287-2703

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	08/22/2020

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