Healthcare Provider Details

I. General information

NPI: 1366743262
Provider Name (Legal Business Name): MSAD 40
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 MANKTOWN RD
WALDOBORO ME
04572-5816
US

IV. Provider business mailing address

320 MANKTOWN RD
WALDOBORO ME
04572-5816
US

V. Phone/Fax

Practice location:
  • Phone: 207-832-5566
  • Fax: 207-832-5566
Mailing address:
  • Phone: 207-832-5566
  • Fax: 207-832-5566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberR036504
License Number StateME

VIII. Authorized Official

Name: MRS. SHELBY COCHRAN GAMMON
Title or Position: DISTRICT NURSE
Credential: RN
Phone: 207-832-5566