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? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 311500000X | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |