Healthcare Provider Details

I. General information

NPI: 1902893555
Provider Name (Legal Business Name): SEASIDE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 BAXTER BLVD
PORTLAND ME
04103-4901
US

IV. Provider business mailing address

850 BAXTER BLVD
PORTLAND ME
04103-4901
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-7878
  • Fax: 207-775-2811
Mailing address:
  • Phone: 207-774-7878
  • Fax: 207-775-2811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number36297
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number36297
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1902
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number36297
License Number StateME

VIII. Authorized Official

Name: MR. KENNETH BOWDEN
Title or Position: CEO
Credential:
Phone: 207-874-2700