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General NPI Number Information
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NPI Number | 1366600371
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Entity Type | Organization
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Legal Business Name | FALLBROOK INC
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Dates
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Enumeration Date | 05/27/2008
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Last Update Date | 05/27/2008
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Provider Practice Location Address
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Address Line | 418 RAYSTREET
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City | PORTLAND
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State | ME
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Zip | 04103
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Country | US
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Telephone | 207-878-0788
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Fax | 207-878-7734
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Provider Business Mailing Address
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Address Line | 418 RAY STREET
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City | PORTLAND
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State | ME
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Zip | 04103
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Country | US
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Telephone | 207-878-0788
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Fax | 207-878-7734
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Authorized Official
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Title or Position | PRESIDENT ADMINISTRATOR
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Name | MR. ROBERT J FEENEY
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Credential | ADMINISTRATOR
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Telephone | 207-878-0788
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number | 372595
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 311500000X
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Taxonomy Name | Alzheimer Center (Dementia Center)
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License Number | 372595
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License Number State | ME
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