Provider Demographics
NPI:1760816276
Name:AVITA STROUDWATER, LLC
Entity Type:Organization
Organization Name:AVITA STROUDWATER, LLC
Other - Org Name:AVITA OF STROUDWATER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-272-2424
Mailing Address - Street 1:71 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803-4430
Mailing Address - Country:US
Mailing Address - Phone:781-272-2424
Mailing Address - Fax:
Practice Address - Street 1:320 SPRING STREET
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092
Practice Address - Country:US
Practice Address - Phone:207-857-9007
Practice Address - Fax:207-857-9017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)