MEDICARE: SOUTH PORTLAND NURSING HOME, INC

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	314000000X	Skilled Nursing Facility	36127	ME

General Provider Information

NPI Number	:	1679575773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH PORTLAND NURSING HOME, INC

Provider Business Mailing Address
First Line	:	42 ANTHOINE ST
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-4403
Country	:	US
Telephone Number	:	207-799-8561
Fax Number	:	207-767-7401

Provider Business Practice Location Address
First Line	:	42 ANTHOINE ST
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-4403
Country	:	US
Telephone Number	:	207-799-8561
Fax Number	:	207-767-7401

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	CINDY N SCOTT
Credential	:
Telephone Number	:	207-799-8561

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	06/14/2013

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