20D0906087 CLIA NUMBER - 75 STATE STREET

Laboratory Demographics

CLIA Number: 20D0906087

Facility Name: 75 STATE STREET

Facility Address:
75 STATE STREET
PORTLAND, ME
ZIP 04101
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Facility Phone Number: 207 775-7775

Facility Type: Assisted Living Facility

Certificate Type: Waiver

NPI Number: 1528201738

Taxonomy: 310400000X - Assisted Living Facility
A facility providing supportive services to individuals who can function independently in most areas of activity, but need assistance and/or monitoring to assure safety and well being.

CLIA Record

Field Name	Field Value
CLIA Number	20D0906087
LAB Type	Assisted Living Facility
Facility Name	75 STATE STREET
Street	75 STATE STREET
City	PORTLAND
State	ME
ZIP	04101
Phone	207 775-7775
CertificateType	4
CertificateEffectiveDate	9/28/2023
CertificateExpirationDate	9/27/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024