Provider Demographics
NPI:1053322792
Name:TOWN OF WALDOBORO
Entity type:Organization
Organization Name:TOWN OF WALDOBORO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SERVICE CHIEF
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:NRP
Authorized Official - Phone:207-832-2160
Mailing Address - Street 1:PO BOX J
Mailing Address - Street 2:
Mailing Address - City:WALDOBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04572-0911
Mailing Address - Country:US
Mailing Address - Phone:207-832-2160
Mailing Address - Fax:207-832-2166
Practice Address - Street 1:1600 ATLANTIC HIGHWAY
Practice Address - Street 2:
Practice Address - City:WALDOBORO
Practice Address - State:ME
Practice Address - Zip Code:04572-6018
Practice Address - Country:US
Practice Address - Phone:207-832-2160
Practice Address - Fax:207-832-6061
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOWN OF WALDOBORO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-10
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME730341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001187OtherANTHEM BC/BS STAR NUMBER
ME137370000Medicaid
ME137370000Medicaid
ME137370000Medicaid