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General NPI Number Information
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NPI Number | 1114168945
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Entity Type | Organization
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Legal Business Name | ST JUDE'S FOSTER HOME
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Dates
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Enumeration Date | 03/06/2009
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Last Update Date | 03/06/2009
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Provider Practice Location Address
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Address Line | 123 WRIGHT STREET
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City | VON BUREN
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State | ME
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Zip | 04785
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Country | US
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Telephone | 207-868-5180
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Fax | 207-868-7781
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Provider Business Mailing Address
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Address Line | 123 WRIGHT STREET
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City | VON BUREN
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State | ME
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Zip | 04785
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Country | US
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Telephone | 207-868-5180
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Fax | 207-868-7781
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Authorized Official
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Title or Position | FOSTER HOME OPERATOR
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Name | MRS. JUDY D GAGNON
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Credential |
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Telephone | 207-868-5180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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