Healthcare Provider Details

I. General information

NPI: 1467097709
Provider Name (Legal Business Name): PINE PEAK CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 CONGRESS ST
PORTLAND ME
04102-2120
US

IV. Provider business mailing address

13 SARA LN
PORTLAND ME
04103-3622
US

V. Phone/Fax

Practice location:
  • Phone: 207-415-6894
  • Fax:
Mailing address:
  • Phone: 207-415-6894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MANASSE SHINGIRO
Title or Position: MANAGING MEMBER
Credential: CRMA
Phone: 207-415-6894