Provider Demographics
NPI:1114921756
Name:BREWSTER PARKE, INC.
Entity Type:Organization
Organization Name:BREWSTER PARKE, INC.
Other - Org Name:BREWSTER CONVALESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHILDS
Authorized Official - Suffix:II
Authorized Official - Credentials:LNHA
Authorized Official - Phone:330-767-4179
Mailing Address - Street 1:360 WABASH AVE N
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44613-1042
Mailing Address - Country:US
Mailing Address - Phone:330-767-3451
Mailing Address - Fax:330-767-3452
Practice Address - Street 1:264 MOHICAN ST NE
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:OH
Practice Address - Zip Code:44613-1126
Practice Address - Country:US
Practice Address - Phone:330-767-4179
Practice Address - Fax:330-767-3907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1482N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0321655Medicaid
OH366264Medicare ID - Type Unspecified