Healthcare Provider Details

I. General information

NPI: 1316497001
Provider Name (Legal Business Name): KATAHDIN VALLEY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

922 DYER BROOK RD
DYER BROOK ME
04747-5028
US

IV. Provider business mailing address

529 S PATTEN RD
PATTEN ME
04765
US

V. Phone/Fax

Practice location:
  • Phone: 207-528-2285
  • Fax: 207-528-2880
Mailing address:
  • Phone: 207-528-2285
  • Fax: 207-528-2880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: CLAUDETTE G HUMPHREY
Title or Position: CEO
Credential:
Phone: 207-528-2285