MEDICARE: PARK STREET HOME WEST PARIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	AUS2232	ME

General Provider Information

NPI Number	:	1073666541
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK STREET HOME WEST PARIS

Provider Business Mailing Address
First Line	:	571 RICHARDSON HOLLOW RD
Second Line	:
City	:	GREENWOOD
State	:	ME
Zip	:	04255-4215
Country	:	US
Telephone Number	:	207-527-2100
Fax Number	:	502-527-2645

Provider Business Practice Location Address
First Line	:	26 PARK STREET
Second Line	:
City	:	WEST PARIS
State	:	ME
Zip	:	04289-5149
Country	:	US
Telephone Number	:	207-674-3372
Fax Number	:	207-527-2645

Authorized Official
Title or Position	:	ADM OWNER
Name	:	MRS. LORI M DEAN
Credential	:
Telephone Number	:	207-527-2170

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	08/22/2020

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Directions to “PARK STREET HOME WEST PARIS ” Practice Location

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