Provider Demographics
NPI:1528200227
Name:BROCKTON HEALTHCARE NETWORK
Entity Type:Organization
Organization Name:BROCKTON HEALTHCARE NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA(MANAGEMENT)
Authorized Official - Phone:614-367-6051
Mailing Address - Street 1:5701 SPRUCE TREE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-7751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5701 SPRUCE TREE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-7751
Practice Address - Country:US
Practice Address - Phone:614-367-6051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSB612704320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness