Provider Demographics
NPI:1104212182
Name:LIBERTY BAY RECOVERY CENTER, LLC
Entity Type:Organization
Organization Name:LIBERTY BAY RECOVERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-379-3300
Mailing Address - Street 1:343 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2006
Mailing Address - Country:US
Mailing Address - Phone:207-772-9800
Mailing Address - Fax:207-536-1511
Practice Address - Street 1:343 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2006
Practice Address - Country:US
Practice Address - Phone:207-772-9800
Practice Address - Fax:207-536-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME684958261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder