Provider Demographics
NPI:1871728964
Name:FREEPORT CONVALSCENT CENTER
Entity type:Organization
Organization Name:FREEPORT CONVALSCENT CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PELKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-874-2700
Mailing Address - Street 1:6 OLD COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-6231
Mailing Address - Country:US
Mailing Address - Phone:207-865-4782
Mailing Address - Fax:
Practice Address - Street 1:6 OLD COUNTY RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-6231
Practice Address - Country:US
Practice Address - Phone:207-865-4782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2005310500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME115110000Medicaid