Provider Demographics
NPI:1023242294
Name:LABRECQUE HOME
Entity type:Organization
Organization Name:LABRECQUE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LABRECQUE
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:207-793-8103
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-0649
Mailing Address - Country:US
Mailing Address - Phone:207-793-8103
Mailing Address - Fax:207-793-2408
Practice Address - Street 1:97 DEMERITT RD
Practice Address - Street 2:
Practice Address - City:WEST NEWFIELD
Practice Address - State:ME
Practice Address - Zip Code:04095
Practice Address - Country:US
Practice Address - Phone:207-793-8103
Practice Address - Fax:207-793-2408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME=========Medicaid