Provider Demographics
NPI:1174689483
Name:SOUTHERN ASSISTED LIVING, LLC.
Entity Type:Organization
Organization Name:SOUTHERN ASSISTED LIVING, LLC.
Other - Org Name:BROOKDALE SKEET CLUB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:LESKOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-918-5000
Mailing Address - Street 1:6737 W WASHINGTON ST
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-5647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1560 SKEET CLUB RD
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-9530
Practice Address - Country:US
Practice Address - Phone:336-869-0301
Practice Address - Fax:336-869-0252
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKDALE SENIOR LIVING INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-29
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804107Medicaid