Healthcare Provider Details

I. General information

NPI: 1265283006
Provider Name (Legal Business Name): COMMON GROUND FRIENDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2024
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 HANCOCK ST STE 3B
BANGOR ME
04401-6573
US

IV. Provider business mailing address

PO BOX 84
BUCKSPORT ME
04416-0084
US

V. Phone/Fax

Practice location:
  • Phone: 207-990-3626
  • Fax:
Mailing address:
  • Phone: 908-239-6417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 13
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: ROGAN O'DONNELL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 609-577-5129