Basic Information
Provider Information | |||||||||
NPI: | 1740322114 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BREA EAST MESA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BROOKDALE EAST MESA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6737 W WASHINGTON ST STE 2300 | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532145650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4149185000 | ||||||||
FaxNumber: | 2063014500 | ||||||||
Practice Location | |||||||||
Address1: | 6145 EAST ARBOR AVENUE | ||||||||
Address2: |   | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 85206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4808321300 | ||||||||
FaxNumber: | 4808321370 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/13/2007 | ||||||||
LastUpdateDate: | 06/13/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RICHARDSON | ||||||||
AuthorizedOfficialFirstName: | BRYAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EVP, CHIEF ADMIN. OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6155648131 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | ALC-4498 | AZ | N |   | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |   | 310400000X | ALC-6785 | AZ | N |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   | 310400000X | AL6354C | AZ | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 205629 | 05 | AZ |   | MEDICAID |