Healthcare Provider Details

I. General information

NPI: 1093752917
Provider Name (Legal Business Name): EASTPORT HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BOYNTON ST
EASTPORT ME
04631-1306
US

IV. Provider business mailing address

PO BOX H
EASTPORT ME
04631-0909
US

V. Phone/Fax

Practice location:
  • Phone: 207-853-6001
  • Fax: 207-853-4028
Mailing address:
  • Phone: 207-853-6001
  • Fax: 207-853-4028

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: MRS. ELLEN KRAJEWSKI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 207-853-6001