Basic Information
| Provider Information | |||||||||
| NPI: | 1669414926 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKS HOME CARE ADVANTAGE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BROOKS AMERICARE HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3599 UNIVERSITY BLVD S | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322164252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043457607 | ||||||||
| FaxNumber: | 9043457284 | ||||||||
| Practice Location | |||||||||
| Address1: | 2730 US 1 S STE GANDH | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320866341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047221515 | ||||||||
| FaxNumber: | 9047221517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9043457473 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 299993785 | FL | N | Agencies | Home Health | 251E00000X | 299993790 | FL | N | Agencies | Home Health | 251E00000X | 299993791 | FL | N | Agencies | Home Health | 251E00000X | 299993789 | FL | N | Agencies | Home Health | 251E00000X | 299993792 | FL | N | Agencies | Home Health | 251E00000X | 299993282 | FL | N | Agencies | Home Health | 251E00000X | 299991968 | FL | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 7144812 | 01 | FL | AETNA PROVIDER NUMBER | OTHER | J9D | 01 | FL | BC/BS PROVIDER NUMBER | OTHER |