Provider Demographics
NPI:1508323247
Name:NORTHBRIDGE AVITA BRUNSWICK II LLC
Entity Type:Organization
Organization Name:NORTHBRIDGE AVITA BRUNSWICK II LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:NOWOKUNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-238-4856
Mailing Address - Street 1:89 ADMIRAL FITCH AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2700
Mailing Address - Country:US
Mailing Address - Phone:207-729-0222
Mailing Address - Fax:207-729-0222
Practice Address - Street 1:89 ADMIRAL FITCH AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2700
Practice Address - Country:US
Practice Address - Phone:207-729-0222
Practice Address - Fax:207-729-0222
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHBRIDGE AVITA BRUNSWICK II LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-01
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)