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General NPI Number Information
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NPI Number | 1255140307
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Entity Type | Organization
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Legal Business Name | BROCK HALLDALE LLC
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Dates
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Enumeration Date | 01/03/2025
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Last Update Date | 01/03/2025
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Provider Practice Location Address
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Address Line | 647 MAINE AVE
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City | FARMINGDALE
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State | ME
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Zip | 04344-1526
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Country | US
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Telephone | 207-622-7082
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Fax |
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Provider Business Mailing Address
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Address Line | 647 MAINE AVE
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City | FARMINGDALE
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State | ME
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Zip | 04344-1526
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Country | US
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Telephone | 207-622-7082
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | KELLY WESBROCK
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Credential |
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Telephone | 207-691-5059
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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