Provider Demographics
NPI:1891239679
Name:AVITA WELLS LLC
Entity Type:Organization
Organization Name:AVITA WELLS LLC
Other - Org Name:AVITA OF WELLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-844-0956
Mailing Address - Street 1:86 SANFORD ROAD
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:ME
Mailing Address - Zip Code:04090
Mailing Address - Country:US
Mailing Address - Phone:207-646-3444
Mailing Address - Fax:207-646-5444
Practice Address - Street 1:86 SANFORD ROAD
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:ME
Practice Address - Zip Code:04090
Practice Address - Country:US
Practice Address - Phone:207-646-3444
Practice Address - Fax:207-646-5444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHBRIDGE COMPANIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)