Healthcare Provider Details

I. General information

NPI: 1114920097
Provider Name (Legal Business Name): CARIBOU NURSING HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 ACADEMY ST
PRESQUE ISLE ME
04769-3102
US

IV. Provider business mailing address

162 ACADEMY ST
PRESQUE ISLE ME
04769-3102
US

V. Phone/Fax

Practice location:
  • Phone: 207-764-0145
  • Fax: 207-764-7327
Mailing address:
  • Phone: 207-764-0145
  • Fax: 207-764-7327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number36153
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number36153
License Number StateME

VIII. Authorized Official

Name: MS. ROSE-MARIE C LOUTEN
Title or Position: ADMINISTRATOR
Credential: MS RD
Phone: 207-764-0145