{
"Npi": {
"NPI": "1962542092",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "Y",
"ParentOrgLBN": "ALLEGIANCE HOSPICE GROUP, INC.",
"ParentOrgTIN": null,
"OrgName": "ALLEGIANCE HOSPICE CARE OF MAINE",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "101 SUN AVENUE NE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "ALBUQUERQUE",
"MailingAddressStateName": "NM",
"MailingAddressPostalCode": "87109-0000",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "505-468-5604",
"MailingAddressFaxNumber": "505-468-4681",
"FirstLinePracticeLocationAddress": "100 FODEN ROAD WEST",
"SecondLinePracticeLocationAddress": "SUITE 200",
"PracticeLocationAddressCityName": "SOUTH PORTLAND",
"PracticeLocationAddressStateName": "ME",
"PracticeLocationAddressPostalCode": "04106-2323",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "207-761-6967",
"PracticeLocationAddressFaxNumber": "207-772-6240",
"EnumerationDate": "02/07/2007",
"LastUpdateDate": "08/03/2011",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "CAVALLO",
"AuthorizedOfficialFirstName": "GLEN",
"AuthorizedOfficialMiddleName": "R",
"AuthorizedOfficialTitle": "PRESIDENT",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "479-996-5900",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "251G00000X",
"TaxonomyName": "Community Based Hospice Care Agency",
"LicenseNumber": "37044",
"LicenseNumberStateCode": "ME",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}