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General NPI Number Information
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NPI Number | 1528201738
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Entity Type | Organization
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Legal Business Name | SEVENTY FIVE STATE STREET
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Dates
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Enumeration Date | 04/17/2009
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Last Update Date | 10/01/2009
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Provider Practice Location Address
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Address Line | 75 STATE ST
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City | PORTLAND
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State | ME
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Zip | 04101-3746
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Country | US
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Telephone | 207-772-2675
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Fax | 207-772-2896
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Provider Business Mailing Address
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Address Line | 75 STATE ST
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City | PORTLAND
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State | ME
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Zip | 04101-3746
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Country | US
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Telephone | 207-772-2675
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Fax | 207-772-2896
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | MR. ANTHONY FORGIONE
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Credential |
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Telephone | 207-772-2675
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | ALLS2085
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License Number State | ME
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