Provider Demographics
NPI:1386913143
Name:FREDERICK'S COUNTRY LIVING RESIDENTIAL HOME
Entity type:Organization
Organization Name:FREDERICK'S COUNTRY LIVING RESIDENTIAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CARE GIVER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-399-3486
Mailing Address - Street 1:50 PALMER RD
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-4950
Mailing Address - Country:US
Mailing Address - Phone:207-399-3486
Mailing Address - Fax:
Practice Address - Street 1:50 PALMER RD
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-4950
Practice Address - Country:US
Practice Address - Phone:207-399-3486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home