Provider Demographics
NPI:1386631547
Name:BROOKHAVEN HEALTH CARE FACILITY LLC
Entity Type:Organization
Organization Name:BROOKHAVEN HEALTH CARE FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-447-8800
Mailing Address - Street 1:801 GAZZOLA DR
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4900
Mailing Address - Country:US
Mailing Address - Phone:631-447-8800
Mailing Address - Fax:631-447-8830
Practice Address - Street 1:801 GAZZOLA DR
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4900
Practice Address - Country:US
Practice Address - Phone:631-447-8800
Practice Address - Fax:631-447-8830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5123304N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01083421Medicaid
NY33-5694Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER