Provider Demographics
NPI:1992249775
Name:AVITA BRUNSWICK LLC
Entity type:Organization
Organization Name:AVITA BRUNSWICK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-844-0956
Mailing Address - Street 1:89 ADMIRAL FITCH WAY
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011
Mailing Address - Country:US
Mailing Address - Phone:207-729-6222
Mailing Address - Fax:
Practice Address - Street 1:89 ADMIRAL FITCH WAY
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011
Practice Address - Country:US
Practice Address - Phone:207-729-6222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHBRIDGE COMPANIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)