Healthcare Provider Details

I. General information

NPI: 1396458790
Provider Name (Legal Business Name): FIDELIS RESIDENTIAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2022
Last Update Date: 12/30/2022
Certification Date: 12/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 RUNNING SPRINGS RD
GORHAM ME
04038-1633
US

IV. Provider business mailing address

54 RUNNING SPRINGS RD
GORHAM ME
04038-1633
US

V. Phone/Fax

Practice location:
  • Phone: 207-213-9053
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. BISENGIMANA GAKUNZI
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 207-213-9053