Healthcare Provider Details

I. General information

NPI: 1265429708
Provider Name (Legal Business Name): MOUNT ST. JOSEPH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 HIGHWOOD ST
WATERVILLE ME
04901-5739
US

IV. Provider business mailing address

7 HIGHWOOD ST
WATERVILLE ME
04901-5739
US

V. Phone/Fax

Practice location:
  • Phone: 207-873-0705
  • Fax: 207-873-6626
Mailing address:
  • Phone: 207-873-0705
  • Fax: 207-873-6626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number1915
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number1915
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1915
License Number StateME

VIII. Authorized Official

Name: KERRY SIROIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 207-873-0705