Healthcare Provider Details

I. General information

NPI: 1841904588
Provider Name (Legal Business Name): EXCELLER SUPPORT SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 12/24/2024
Certification Date: 12/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 LISBON ST FL 2
LEWISTON ME
04240-7234
US

IV. Provider business mailing address

168 LISBON ST FL 2
LEWISTON ME
04240-7234
US

V. Phone/Fax

Practice location:
  • Phone: 207-310-3101
  • Fax:
Mailing address:
  • Phone: 207-310-3101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: KEVIN GARNON NISHIMWE
Title or Position: CHIEF EXECUTIVE OFFICER (CEO)
Credential:
Phone: 207-352-8710