Healthcare Provider Details

I. General information

NPI: 1770722902
Provider Name (Legal Business Name): MAINE RESOURCE DEVELOPMENT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 LINCOLN ST
PORTLAND ME
04103-4408
US

IV. Provider business mailing address

18 LINCOLN ST
PORTLAND ME
04103-4408
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-2552
  • Fax:
Mailing address:
  • Phone: 207-774-2552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberALLS3219
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberALLS3219
License Number StateME

VIII. Authorized Official

Name: JERRY BRUCE KEENE
Title or Position: ADMINISTRATOR
Credential:
Phone: 207-774-2552