MEDICARE: SOUTHERN HARBOR ELDERCARE SERVICES

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	310400000X	Assisted Living Facility		ME
2	311ZA0620X	Adult Care Home Facility		ME

General Provider Information

NPI Number	:	1750873592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN HARBOR ELDERCARE SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 220
Second Line	:
City	:	NORTH HAVEN
State	:	ME
Zip	:	04853
Country	:	US
Telephone Number	:	207-867-2345
Fax Number	:	207-863-5027

Provider Business Practice Location Address
First Line	:	12 PULPIT HARBOR ROAD
Second Line	:
City	:	NORTH HAVEN
State	:	ME
Zip	:	04853
Country	:	US
Telephone Number	:	207-867-2345
Fax Number	:	207-863-5027

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. KATHI LOVELL
Credential	:
Telephone Number	:	207-867-4633

Provider Enumeration Date	:	06/06/2018
Last Update Date	:	06/06/2018

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