Basic Information
| Provider Information | |||||||||
| NPI: | 1508915190 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKDALE HOME HEALTH LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BROOKDALE HOME HEALTH MELBOURNE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 111 WESTWOOD PL | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152212250 | ||||||||
| FaxNumber: | 6152212280 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 NW CAROLINA ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WEST MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329044107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219525550 | ||||||||
| FaxNumber: | 3219525502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 06/18/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGLASSON | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR REGULATORY PRACTICES | ||||||||
| AuthorizedOfficialTelephone: | 6155648034 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 299991965 | FL | Y | Agencies | Home Health |
No ID Information.