Basic Information
| Provider Information | |||||||||
| NPI: | 1497750954 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROOKSVILLE HEALTH CARE CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROOKSVILLE HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1114 CHATMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346013104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527966701 | ||||||||
| FaxNumber: | 3527966514 | ||||||||
| Practice Location | |||||||||
| Address1: | 1114 CHATMAN BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346013104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527966701 | ||||||||
| FaxNumber: | 3527966514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 02/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | MOAK | ||||||||
| AuthorizedOfficialFirstName: | WANDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3527966701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF 1063096 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.