Healthcare Provider Details

I. General information

NPI: 1477881951
Provider Name (Legal Business Name): FALLBROOK RESIDENTIAL CARE FACILITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 11/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 RAY ST
PORTLAND ME
04103-3934
US

IV. Provider business mailing address

179 LISBON ST CENTERVILLE PLAZA BUILDING 2ND FLOOR
LEWISTON ME
04240-7248
US

V. Phone/Fax

Practice location:
  • Phone: 207-878-0788
  • Fax:
Mailing address:
  • Phone: 207-786-3554
  • Fax: 207-786-8507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateME

VIII. Authorized Official

Name: MR. GLEN G CYR
Title or Position: VP FINANCE
Credential:
Phone: 207-786-3554