Provider Demographics
NPI:1497750954
Name:BROOKSVILLE HEALTH CARE CENTER LLC
Entity Type:Organization
Organization Name:BROOKSVILLE HEALTH CARE CENTER LLC
Other - Org Name:BROOKSVILLE HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-796-6701
Mailing Address - Street 1:1114 CHATMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3104
Mailing Address - Country:US
Mailing Address - Phone:352-796-6701
Mailing Address - Fax:352-796-6514
Practice Address - Street 1:1114 CHATMAN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3104
Practice Address - Country:US
Practice Address - Phone:352-796-6701
Practice Address - Fax:352-796-6514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF 1063096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
105297Medicare Oscar/Certification