Provider Demographics
NPI:1487417895
Name:EAT PLAY GROW OT LLC
Entity type:Organization
Organization Name:EAT PLAY GROW OT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-312-8437
Mailing Address - Street 1:188 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5515
Mailing Address - Country:US
Mailing Address - Phone:207-312-8437
Mailing Address - Fax:
Practice Address - Street 1:120 CENTER ST STE 109
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-6339
Practice Address - Country:US
Practice Address - Phone:207-312-8437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1467087379Medicaid