Provider Demographics
NPI:1295321487
Name:GREAT RESIDENTIAL HOME CARE LLC
Entity type:Organization
Organization Name:GREAT RESIDENTIAL HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BIZIMANA
Authorized Official - Suffix:
Authorized Official - Credentials:DSP
Authorized Official - Phone:207-518-1535
Mailing Address - Street 1:238 AUBURN ST APT D37
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2150
Mailing Address - Country:US
Mailing Address - Phone:207-518-1535
Mailing Address - Fax:
Practice Address - Street 1:238 AUBURN ST APT D37
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2150
Practice Address - Country:US
Practice Address - Phone:207-518-1535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-12
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities