Healthcare Provider Details

I. General information

NPI: 1497810964
Provider Name (Legal Business Name): PEREGRINE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 FOREST AVENUE
PORTLAND ME
04103
US

IV. Provider business mailing address

1011 FOREST AVENUE
PORTLAND ME
04103
US

V. Phone/Fax

Practice location:
  • Phone: 207-879-0847
  • Fax: 207-857-2919
Mailing address:
  • Phone: 207-879-0847
  • Fax: 207-857-2919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: CAROL A. PAPCIAK
Title or Position: FINANCIAL MANAGER
Credential:
Phone: 207-879-0847