Provider Demographics
NPI:1518167469
Name:BRENTWOODMEADOWHEALTHCAREASSODBABRENTWOOD RETIREMENT COMMUNITY
Entity Type:Organization
Organization Name:BRENTWOODMEADOWHEALTHCAREASSODBABRENTWOOD RETIREMENT COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-746-6611
Mailing Address - Street 1:1900 W ALPHA CT
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-7507
Mailing Address - Country:US
Mailing Address - Phone:352-746-6611
Mailing Address - Fax:352-746-6662
Practice Address - Street 1:1900 W ALPHA CT
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-7507
Practice Address - Country:US
Practice Address - Phone:352-746-6611
Practice Address - Fax:352-746-6662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL4987310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility