Provider Demographics
NPI:1902887060
Name:68 DEVONSHIRE STREET CORP.
Entity Type:Organization
Organization Name:68 DEVONSHIRE STREET CORP.
Other - Org Name:PORTLAND CENTER FOR ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-874-2700
Mailing Address - Street 1:68 DEVONSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4431
Mailing Address - Country:US
Mailing Address - Phone:207-772-2893
Mailing Address - Fax:
Practice Address - Street 1:68 DEVONSHIRE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4431
Practice Address - Country:US
Practice Address - Phone:207-772-2893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS 1625310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME131950000Medicaid