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General NPI Number Information
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NPI Number | 1336919091
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Entity Type | Organization
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Legal Business Name | AGING GRACE HOUSE CALLS, PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 01/04/2024
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Last Update Date | 02/26/2024
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Provider Practice Location Address
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Address Line | 21 E SUMMER ST
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City | BANGOR
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State | ME
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Zip | 04401-5513
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Country | US
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Telephone | 207-573-0710
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Fax |
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Provider Business Mailing Address
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Address Line | 21 E SUMMER ST
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City | BANGOR
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State | ME
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Zip | 04401-5513
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KATHRYN M MORDINO
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Credential | ANP-BC
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Telephone | 617-435-7601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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