Healthcare Provider Details

I. General information

NPI: 1982081154
Provider Name (Legal Business Name): BONFIRE BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 INDUSTRIAL WAY STE 11E
ROCHESTER NH
03867-6202
US

IV. Provider business mailing address

10461 MILL RUN CIR STE 810
OWINGS MILLS MD
21117-5549
US

V. Phone/Fax

Practice location:
  • Phone: 603-617-4815
  • Fax:
Mailing address:
  • Phone: 410-807-8471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIM BROWN
Title or Position: DIRECTOR OF COMPLIANCE
Credential:
Phone: 870-243-7219