Healthcare Provider Details

I. General information

NPI: 1609917889
Provider Name (Legal Business Name): CITY OF PORTLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 BRIGHTON AVE
PORTLAND ME
04102-1025
US

IV. Provider business mailing address

1145 BRIGHTON AVE
PORTLAND ME
04102-1025
US

V. Phone/Fax

Practice location:
  • Phone: 207-541-6500
  • Fax: 207-541-6555
Mailing address:
  • Phone: 207-541-6500
  • Fax: 207-541-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number36498
License Number StateME

VIII. Authorized Official

Name: MRS. JERALYN P LOGUE
Title or Position: FINANCE ADMINISTRATOR
Credential:
Phone: 207-541-6544