Healthcare Provider Details

I. General information

NPI: 1366600371
Provider Name (Legal Business Name): FALLBROOK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 RAYSTREET
PORTLAND ME
04103
US

IV. Provider business mailing address

418 RAY STREET
PORTLAND ME
04103
US

V. Phone/Fax

Practice location:
  • Phone: 207-878-0788
  • Fax: 207-878-7734
Mailing address:
  • Phone: 207-878-0788
  • Fax: 207-878-7734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number372595
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number372595
License Number StateME

VIII. Authorized Official

Name: MR. ROBERT J FEENEY
Title or Position: PRESIDENT ADMINISTRATOR
Credential: ADMINISTRATOR
Phone: 207-878-0788