Provider Demographics
NPI:1154322808
Name:FRYEBURG HEALTH CARE CENTER, INC.
Entity Type:Organization
Organization Name:FRYEBURG HEALTH CARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-786-0111
Mailing Address - Street 1:197 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-5125
Mailing Address - Country:US
Mailing Address - Phone:207-786-0111
Mailing Address - Fax:207-783-5016
Practice Address - Street 1:70 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:FRYEBURG
Practice Address - State:ME
Practice Address - Zip Code:04037-1524
Practice Address - Country:US
Practice Address - Phone:207-786-0111
Practice Address - Fax:207-783-5016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1942314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME107350000Medicaid
ME107350000Medicaid