Healthcare Provider Details

I. General information

NPI: 1770798175
Provider Name (Legal Business Name): RSU # 21
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 FLETCHER ST
KENNEBUNK ME
04043-6850
US

IV. Provider business mailing address

87 FLETCHER ST
KENNEBUNK ME
04043-6850
US

V. Phone/Fax

Practice location:
  • Phone: 207-985-1100
  • Fax:
Mailing address:
  • Phone: 207-985-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier104380001
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name: SUSAN MULSOW
Title or Position: DIRECTOR OF SPECIAL SERVICES
Credential:
Phone: 207-985-1100