Healthcare Provider Details

I. General information

NPI: 1962506675
Provider Name (Legal Business Name): EXUBERANT LIVING, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 HAMMOND ST
BANGOR ME
04401-4328
US

IV. Provider business mailing address

216 NORTH RD
DIXMONT ME
04932-3212
US

V. Phone/Fax

Practice location:
  • Phone: 207-992-4042
  • Fax: 207-992-4043
Mailing address:
  • Phone: 207-992-4042
  • Fax: 207-992-4043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberTO1993
License Number StateME

VIII. Authorized Official

Name: MRS. CAROL J LANE
Title or Position: PRESIDENT
Credential: PT
Phone: 207-992-4042