Provider Demographics
NPI:1558329185
Name:BROOKSIDE CARE CENTER
Entity Type:Organization
Organization Name:BROOKSIDE CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDT
Authorized Official - Suffix:
Authorized Official - Credentials:NHA RN
Authorized Official - Phone:262-653-3800
Mailing Address - Street 1:3506 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144
Mailing Address - Country:US
Mailing Address - Phone:262-653-3800
Mailing Address - Fax:262-653-3850
Practice Address - Street 1:3506 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144
Practice Address - Country:US
Practice Address - Phone:262-653-3800
Practice Address - Fax:262-653-3850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3155314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20130300Medicaid
WI20130300Medicaid
WI525556Medicare Oscar/Certification