Provider Demographics
NPI:1417440488
Name:BROOKE HAVEN CARE HOME LLC
Entity Type:Organization
Organization Name:BROOKE HAVEN CARE HOME LLC
Other - Org Name:BROOKE HAVEN CARE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TYRIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-308-1806
Mailing Address - Street 1:4009 COTTAGE PARK CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-8087
Mailing Address - Country:US
Mailing Address - Phone:817-308-1806
Mailing Address - Fax:
Practice Address - Street 1:1540 BERCKMANS RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-1500
Practice Address - Country:US
Practice Address - Phone:817-308-1806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1518471986OtherNPI