Basic Information
| Provider Information | |||||||||
| NPI: | 1356537096 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KATAHDIN VALLEY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 500 | ||||||||
| Address2: | |||||||||
| City: | PATTEN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047650500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075282285 | ||||||||
| FaxNumber: | 2075282880 | ||||||||
| Practice Location | |||||||||
| Address1: | 489 STATE ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079737000 | ||||||||
| FaxNumber: | 2075282880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2007 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | HUMPHREY | ||||||||
| AuthorizedOfficialFirstName: | DURWARD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2075282285 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 431497600 | 05 | ME | MEDICAID |