Provider Demographics
NPI:1346595964
Name:BROADMORE SENIOR LIVING
Entity Type:Organization
Organization Name:BROADMORE SENIOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MIRACLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-764-4622
Mailing Address - Street 1:826 MEADOW VIEW RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-9535
Mailing Address - Country:US
Mailing Address - Phone:423-764-4622
Mailing Address - Fax:423-764-4822
Practice Address - Street 1:826 MEADOW VIEW RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-9535
Practice Address - Country:US
Practice Address - Phone:423-764-4622
Practice Address - Fax:423-764-4822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNACL0000000119310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA3762000Medicaid