Provider Demographics
NPI:1508292582
Name:BRENTWOOD MEADOWS, LLC
Entity Type:Organization
Organization Name:BRENTWOOD MEADOWS, LLC
Other - Org Name:BRENTWOOD MEADOWS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF LICENSE AND REGULATION
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:SALEE
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:812-598-8989
Mailing Address - Street 1:4488 ROSLIN RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8590
Mailing Address - Country:US
Mailing Address - Phone:812-858-7200
Mailing Address - Fax:
Practice Address - Street 1:4488 ROSLIN RD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8590
Practice Address - Country:US
Practice Address - Phone:812-858-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRENTWOOD MEADOWS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043877A2084P0800X
IN71003322A364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN154055Medicare Oscar/Certification