Provider Demographics
NPI:1336282912
Name:BROWN ROAD SENIOR HOUSING, LLC
Entity Type:Organization
Organization Name:BROWN ROAD SENIOR HOUSING, LLC
Other - Org Name:GRAND COURT MESA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-401-1369
Mailing Address - Street 1:262 E. BROWN RD.
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201
Mailing Address - Country:US
Mailing Address - Phone:480-844-7336
Mailing Address - Fax:480-844-7045
Practice Address - Street 1:262 E BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3545
Practice Address - Country:US
Practice Address - Phone:480-844-7336
Practice Address - Fax:480-844-7045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALC-4140310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ797087Medicaid