NPIMap

Organization Active NPI

Seaside Healthcare LLC

Doing business as Seaside Retirement and Nursing Center

  • Skilled Nursing Facility
  • Portland, ME
National Provider Identifier
1902893555
Registry record updated May 20, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
1902 Issued in ME
Legal business name
SEASIDE HEALTHCARE LLC
Doing business as
Seaside Retirement and Nursing Center
Practice address
850 Baxter Blvd
Portland, ME 04103-4901
Phone
(207) 774-7878
Fax
(207) 775-2811
NPI assigned
Sep 29, 2005
Last updated
May 20, 2009By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 20, 2009

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

Authorized official

Name
Mr. Kenneth Bowden
Title
Ceo
Phone
(207) 874-2700

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapy Clinic/Center 261QP2000X 36297 ME
Occupational Medicine Clinic/Center 261QX0100X 36297 ME
Skilled Nursing Facility 314000000X 1902 ME Primary
Speech-Language Pathologist 235Z00000X 36297 ME

Addresses

Primary practice location

850 Baxter Blvd
Portland, ME 04103-4901

Mailing address

850 Baxter Blvd
Portland, ME 04103-4901
Phone (207) 774-7878

Other identifiers 2

IdentifierTypeStateIssuer
130930000MedicaidME
13093001MedicaidME

Other names 1

  • Seaside Retirement and Nursing Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130918000139 ME Part A Provider - Skilled Nursing Facility 2163666975 Practice locations: Portland, ME

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1902893555. Details of each certification follow.

Skilled nursing facility certification: CCN 205074A

Legal name
SEASIDE HEALTHCARE LLC
Organization structure
LLCProprietary
Enrollment address
850 Baxter Blvd
Portland, ME 04103-4901
Nursing home name
SEASIDE HEALTHCARE LLC
Affiliated entity
FIRST ATLANTIC HEALTHCARE

National Provider Directory

National Provider Directory
Tax ID family
Seaside Healthcare2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

850 Baxter Blvd
Portland, ME 04103
Phone (207) 774-7878

Ownership & related parties

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Craig G Coffin Individual 5% Or Greater Indirect Ownership Interest Jun 30, 2019 66.67%
Adp of the SNF Jun 26, 2019
Amanda Ra Roberts Individual Operational/Managerial Control Oct 1, 2024
Adp of the SNF Oct 18, 2024
Kenneth W Bowden Individual 5% Or Greater Indirect Ownership Interest Jun 26, 2019 33.33%
Adp of the SNF Jun 26, 2019
Elizabeth McGuire Individual Operational/Managerial Control May 16, 2021
Adp of the SNF May 16, 2021
First Atlantic Healthcare Inc Organization, South Portland, ME Corporation, Management services company, For-profit, Chain home office Operational/Managerial Control Oct 31, 1997 100%
Adp of the SNF Feb 4, 2025
Andrea Otis-Higgins Individual Operational/Managerial Control May 11, 2015
Adp of the SNF May 11, 2015
KWB Holdings, LLC Organization, South Portland, ME LLC, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jun 26, 2019 33.33%
Adp of the SNF Jun 26, 2019
Faraday Holdings LLC Organization, South Portland, ME LLC, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Jun 26, 2019 66.67%
Adp of the SNF Jun 26, 2019
Wanda Pelkey Individual Corporate OfficerCeo Oct 1, 2024 100%
Operational/Managerial Control Oct 1, 2024
Adp of the SNF Oct 1, 2024

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 9

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1127952000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1242777600000",
    "number": "1902893555",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "850 BAXTER BLVD",
            "city": "PORTLAND",
            "state": "ME",
            "postal_code": "041034901",
            "telephone_number": "207-774-7878",
            "fax_number": "207-775-2811"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "850 BAXTER BLVD",
            "city": "PORTLAND",
            "state": "ME",
            "postal_code": "041034901",
            "telephone_number": "207-774-7878",
            "fax_number": "207-775-2811"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SEASIDE HEALTHCARE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-29",
        "last_updated": "2009-05-20",
        "status": "A",
        "authorized_official_last_name": "BOWDEN",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "207-874-2700",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "ME",
            "license": "36297",
            "primary": false
        },
        {
            "code": "261QX0100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Occupational Medicine",
            "state": "ME",
            "license": "36297",
            "primary": false
        },
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "ME",
            "license": "1902",
            "primary": true
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "ME",
            "license": "36297",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "130930000",
            "state": "ME"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "13093001",
            "state": "ME"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Seaside Retirement and Nursing Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Portland, ME

Sources for this page

Verify at the official NPI Registry.