Healthcare Provider Details

I. General information

NPI: 1528202793
Provider Name (Legal Business Name): CAROLE ELAINE RIDEOUT DSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 05/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 BIRMINGHAM RD
CHELSEA ME
04330-1190
US

IV. Provider business mailing address

222 BIRMINGHAM RD
CHELSEA ME
04330-1190
US

V. Phone/Fax

Practice location:
  • Phone: 207-582-2440
  • Fax:
Mailing address:
  • Phone: 207-582-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: