Healthcare Provider Details

I. General information

NPI: 1710100839
Provider Name (Legal Business Name): MAINE COAST MOBILE MED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 12/24/2019
Certification Date: 12/24/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1576 HAMMOND ST STE C
BANGOR ME
04401-5751
US

IV. Provider business mailing address

PO BOX 1393
ELLSWORTH ME
04605-1393
US

V. Phone/Fax

Practice location:
  • Phone: 207-404-4894
  • Fax: 207-907-4911
Mailing address:
  • Phone: 207-460-8882
  • Fax: 207-907-4911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberRT3575
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number
License Number State

VIII. Authorized Official

Name: PHILLIP FORST
Title or Position: OWNER
Credential:
Phone: 207-497-2996