Healthcare Provider Details

I. General information

NPI: 1275359556
Provider Name (Legal Business Name): BROCK LODGES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MAIN ST
SPRINGVALE ME
04083-1843
US

IV. Provider business mailing address

51 MAIN ST
SPRINGVALE ME
04083-1843
US

V. Phone/Fax

Practice location:
  • Phone: 207-324-4757
  • Fax:
Mailing address:
  • Phone: 207-324-4757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KELLY WESBROCK
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 207-691-5059