Healthcare Provider Details

I. General information

NPI: 1891061115
Provider Name (Legal Business Name): FULLCIRCLE SUPPORTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 STODDARD LN
HALLOWELL ME
04347-1429
US

IV. Provider business mailing address

6 STODDARD LN
HALLOWELL ME
04347-1429
US

V. Phone/Fax

Practice location:
  • Phone: 207-620-7196
  • Fax:
Mailing address:
  • Phone: 207-620-7196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number636428
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number636428
License Number StateME

VIII. Authorized Official

Name: MARK EDWARD MCNEFF
Title or Position: VICE PRESIDENT
Credential:
Phone: 207-485-4005