Healthcare Provider Details

I. General information

NPI: 1134196124
Provider Name (Legal Business Name): PARK STREET GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 PARK ST SUITE 202
ROCKLAND ME
04841
US

IV. Provider business mailing address

58 PARK ST SUITE 202
ROCKLAND ME
04841
US

V. Phone/Fax

Practice location:
  • Phone: 207-594-4985
  • Fax: 207-594-4974
Mailing address:
  • Phone: 207-594-4985
  • Fax: 207-594-4974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number100360000
License Number StateME

VIII. Authorized Official

Name: PAULA M HOUST
Title or Position: PRESIDENT
Credential:
Phone: 207-594-4985