NPIMap

Organization Active NPI

Port Resources

  • Intellectual and/or Developmental Disabilities Residential Treatment Facility
  • South Portland, ME
National Provider Identifier
1053467779
Registry record updated Jul 16, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual and/or Developmental Disabilities Residential Treatment FacilityTaxonomy code 320600000X
License
388111 Issued in ME
Legal business name
PORT RESOURCES
Practice address
280B Gannett Dr
South Portland, ME 04106-6940
Phone
(207) 828-0048
Fax
(207) 772-3743
NPI assigned
Jan 26, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 16, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Robin Defreest
Title
Director of Finance
Phone
(207) 828-0048

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual and/or Developmental Disabilities Residential Treatment Facility 320600000X 388111 ME Primary

Addresses

Primary practice location

280B Gannett Dr
South Portland, ME 04106-6940

Mailing address

280B Gannett Dr
South Portland, ME 04106-6940
Phone (207) 828-0048

Other identifiers 1

IdentifierTypeStateIssuer
110580000MedicaidME

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ME

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150102000068 ME Part B Supplier - Clinic/Group Practice 5496078206 Receives reassigned benefits from 7 practitioners
Practice locations: South Portland, ME

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
20D2207557Port Resources280B Gannett Drive, South Portland, ME 04106Certificate of waiverDec 28, 2026

National Provider Directory

National Provider Directory

Locations

280 Gannett Dr
Ste B
South Portland, ME 04106
Phone (207) 828-0048

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1169769600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1405468800000",
    "number": "1053467779",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "280B GANNETT DR",
            "city": "SOUTH PORTLAND",
            "state": "ME",
            "postal_code": "041066940",
            "telephone_number": "207-828-0048",
            "fax_number": "207-772-3743"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "280B GANNETT DR",
            "city": "SOUTH PORTLAND",
            "state": "ME",
            "postal_code": "041066940",
            "telephone_number": "207-828-0048",
            "fax_number": "207-772-3743"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PORT RESOURCES",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-26",
        "last_updated": "2014-07-16",
        "status": "A",
        "authorized_official_last_name": "DEFREEST",
        "authorized_official_first_name": "ROBIN",
        "authorized_official_title_or_position": "DIRECTOR OF FINANCE",
        "authorized_official_telephone_number": "207-828-0048",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "ME",
            "license": "388111",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "110580000",
            "state": "ME"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in South Portland, ME

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.