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General NPI Number Information
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NPI Number | 1417267535
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Entity Type | Organization
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Legal Business Name | SIESTA HAVEN II
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Dates
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Enumeration Date | 10/08/2010
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Last Update Date | 10/08/2010
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Provider Practice Location Address
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Address Line | 33 JAMES ST
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City | BANGOR
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State | ME
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Zip | 04401-4634
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Country | US
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Telephone | 207-944-6328
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3715
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City | BREWER
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State | ME
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Zip | 04412-3715
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Country | US
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Telephone | 207-944-6328
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Fax |
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | MS. WENDY LAINEZ
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Credential |
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Telephone | 207-944-6328
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | ALLS 4085
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License Number State | ME
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