Healthcare Provider Details

I. General information

NPI: 1144274564
Provider Name (Legal Business Name): COMMUNITY LIVING ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 SCHOOL ST
HOULTON ME
04730-2010
US

IV. Provider business mailing address

45 SCHOOL ST
HOULTON ME
04730-2010
US

V. Phone/Fax

Practice location:
  • Phone: 207-532-9446
  • Fax: 207-532-1359
Mailing address:
  • Phone: 207-532-9446
  • Fax: 207-532-1359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number36310
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberALLS2160
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberALLS2161
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberALLS1110
License Number StateME
# 5
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberALLS2148
License Number StateME
# 6
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberALLS2155
License Number StateME
# 7
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberALLS2154
License Number StateME
# 8
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberALLS2193
License Number StateME
# 9
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberALLS2147
License Number StateME
# 10
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number36274
License Number StateME

VIII. Authorized Official

Name: MR. SHANNON JON HOGAN
Title or Position: FINANCE MANAGER
Credential:
Phone: 207-532-9446