Healthcare Provider Details

I. General information

NPI: 1619043098
Provider Name (Legal Business Name): PENQUIS C.A.P., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 HARLOW ST
BANGOR ME
04401-4952
US

IV. Provider business mailing address

PO BOX 1162
BANGOR ME
04402-1162
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-3500
  • Fax:
Mailing address:
  • Phone: 207-973-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KARA HAY
Title or Position: CEO
Credential:
Phone: 207-973-3500