Healthcare Provider Details

I. General information

NPI: 1457688962
Provider Name (Legal Business Name): OAK GROVE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 COOL ST
WATERVILLE ME
04901-5221
US

IV. Provider business mailing address

27 COOL ST
WATERVILLE ME
04901-5221
US

V. Phone/Fax

Practice location:
  • Phone: 207-873-0721
  • Fax: 207-877-2287
Mailing address:
  • Phone: 207-873-0721
  • Fax: 207-877-2287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPA3557
License Number StateME

VIII. Authorized Official

Name: MR. JEREMY PAULES
Title or Position: PHYSICAL THERAPIST ASSISTANT
Credential: PTA
Phone: 207-873-0721