Provider Demographics
NPI:1982081154
Name:BONFIRE BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:BONFIRE BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-243-7219
Mailing Address - Street 1:10461 MILL RUN CIR STE 810
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5549
Mailing Address - Country:US
Mailing Address - Phone:410-807-8471
Mailing Address - Fax:
Practice Address - Street 1:35 INDUSTRIAL WAY STE 11E
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03867-6202
Practice Address - Country:US
Practice Address - Phone:603-617-4815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-27
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3127880Medicaid
NH3103840Medicaid