=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194408245
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODCREST CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2023
-----------------------------------------------------
Last Update Date | 08/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 218 FERN RD
-----------------------------------------------------
City | DEXTER
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04930-2609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-924-3818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 PEARL ST, STE 410E #144
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-949-2300
-----------------------------------------------------
Fax | 207-848-8480
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDIENT
-----------------------------------------------------
Name | DEREK E WOOD
-----------------------------------------------------
Credential | ADMINISTRATOR
-----------------------------------------------------
Telephone | 207-949-2300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------