Healthcare Provider Details

I. General information

NPI: 1952271207
Provider Name (Legal Business Name): PINECREST HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 WEST ST
BANGOR ME
04401-5809
US

IV. Provider business mailing address

42 DANA DR
BANGOR ME
04401-2749
US

V. Phone/Fax

Practice location:
  • Phone: 207-922-0049
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. GEORGIA SIMONE SAMUELS
Title or Position: CO-OWNER
Credential:
Phone: 207-922-0049