=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740415488
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SHOOTING STARS PROGRAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2009
-----------------------------------------------------
Last Update Date | 05/26/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 152 US ROUTE 1 4
-----------------------------------------------------
City | SCARBOROUGH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04074-8365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-883-5882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 HIGH POINT RD
-----------------------------------------------------
City | SCARBOROUGH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04074-9027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-883-8095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. RUTH HUGHES
-----------------------------------------------------
Credential | M.ED.
-----------------------------------------------------
Telephone | 207-883-5882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------