Provider Demographics
NPI:1336321413
Name:BROOKSIDE COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:BROOKSIDE COMMUNITY HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LUCINDA
Authorized Official - Middle Name:BRANNON
Authorized Official - Last Name:BAZILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-231-9810
Mailing Address - Street 1:2023 VALE RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-3834
Mailing Address - Country:US
Mailing Address - Phone:510-231-9810
Mailing Address - Fax:
Practice Address - Street 1:2023 VALE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3834
Practice Address - Country:US
Practice Address - Phone:510-231-9810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASTATE IDENT NUMBEROtherEAPC70699F