=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225124050
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOULTON BAND OF MALISEET INDIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2006
-----------------------------------------------------
Last Update Date | 04/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 CLOVER CIRCLE
-----------------------------------------------------
City | HOULTON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-532-4229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 BELL RD STE 2
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04730-6704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-532-4229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OFFICE MANAGE
-----------------------------------------------------
Name | MS. PAMELA J PALM
-----------------------------------------------------
Credential | CPC
-----------------------------------------------------
Telephone | 207-532-4229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------