Basic Information
| Provider Information | |||||||||
| NPI: | 1326274622 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE OPPORTUNITY ALLIANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 LYDIA LN | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078741175 | ||||||||
| FaxNumber: | 2078741181 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 LYDIA LN | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078741175 | ||||||||
| FaxNumber: | 2078741181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 10/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | HAWLEY | ||||||||
| AuthorizedOfficialFirstName: | LAUREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2075235018 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 105460008 | 05 | ME | MEDICAID | 105460005 | 05 | ME | MEDICAID | 105460000 | 05 | ME | MEDICAID | 105460010 | 05 | ME | MEDICAID | 105460011 | 05 | ME | MEDICAID |