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General NPI Number Information
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NPI Number | 1104212182
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Entity Type | Organization
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Legal Business Name | LIBERTY BAY RECOVERY CENTER, LLC
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Dates
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Enumeration Date | 04/07/2015
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Last Update Date | 09/04/2024
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Provider Practice Location Address
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Address Line | 343 FOREST AVE
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City | PORTLAND
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State | ME
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Zip | 04101-2006
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Country | US
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Telephone | 207-772-9800
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Fax | 207-536-1511
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Provider Business Mailing Address
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Address Line | 343 FOREST AVE
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City | PORTLAND
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State | ME
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Zip | 04101-2006
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Country | US
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Telephone | 207-772-9800
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Fax | 207-536-1511
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Authorized Official
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Title or Position | VP, TREASURER
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Name | BRUCE JARVIE
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Credential |
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Telephone | 214-379-3300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 684958
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License Number State | ME
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