Healthcare Provider Details

I. General information

NPI: 1336919091
Provider Name (Legal Business Name): AGING GRACE HOUSE CALLS, PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 E SUMMER ST
BANGOR ME
04401-5513
US

IV. Provider business mailing address

21 E SUMMER ST
BANGOR ME
04401-5513
US

V. Phone/Fax

Practice location:
  • Phone: 207-573-0710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN M MORDINO
Title or Position: CEO
Credential: ANP-BC
Phone: 617-435-7601