Basic Information
| Provider Information | |||||||||
| NPI: | 1508198037 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST ANDRE HOME INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 168 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040053093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072823351 | ||||||||
| FaxNumber: | 2072828733 | ||||||||
| Practice Location | |||||||||
| Address1: | 168 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040053093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072823351 | ||||||||
| FaxNumber: | 2072828733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2010 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GAUVIN | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2072823351 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 168230000 | 05 | ME | MEDICAID | 435407000 | 05 | ME | MEDICAID |