Healthcare Provider Details

I. General information

NPI: 1144935644
Provider Name (Legal Business Name): FIDELITY RESIDENTIAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 SHERMAN ST APT 5
PORTLAND ME
04101-2203
US

IV. Provider business mailing address

56 SHERMAN ST APT 5
PORTLAND ME
04101-2203
US

V. Phone/Fax

Practice location:
  • Phone: 312-402-1521
  • Fax:
Mailing address:
  • Phone: 312-402-1521
  • 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. JEAN CLAUDE MUNYANEZA SR.
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 312-402-1521