Basic Information
| Provider Information | |||||||||
| NPI: | 1346595964 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROADMORE SENIOR LIVING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 826 MEADOW VIEW RD | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376209535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237644622 | ||||||||
| FaxNumber: | 4237644822 | ||||||||
| Practice Location | |||||||||
| Address1: | 826 MEADOW VIEW RD | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376209535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237644622 | ||||||||
| FaxNumber: | 4237644822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2012 | ||||||||
| LastUpdateDate: | 07/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | MIRACLE | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | NICOLE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 4237644622 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | ACL0000000119 | TN | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | A3762000 | 05 | TN | MEDICAID |