Provider Demographics
NPI:1649404609
Name:ROBERTS, RANDALL S
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:S
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 226
Mailing Address - Street 2:
Mailing Address - City:PATTEN
Mailing Address - State:ME
Mailing Address - Zip Code:04765-0226
Mailing Address - Country:US
Mailing Address - Phone:207-538-5279
Mailing Address - Fax:
Practice Address - Street 1:52 GARDNER STREET
Practice Address - Street 2:APT A
Practice Address - City:PATTEN
Practice Address - State:ME
Practice Address - Zip Code:04765
Practice Address - Country:US
Practice Address - Phone:207-538-5279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432861500Medicaid