Basic Information
| Provider Information | |||||||||
| NPI: | 1538399530 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE IRIS NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 189 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041022909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077746273 | ||||||||
| FaxNumber: | 2077740679 | ||||||||
| Practice Location | |||||||||
| Address1: | 189 PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041022909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077746273 | ||||||||
| FaxNumber: | 2077740679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2009 | ||||||||
| LastUpdateDate: | 07/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | TRABOLD | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIR OF FINANCE & ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 2077746273 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 101600001 | 05 | ME | MEDICAID |