Provider Demographics
NPI:1568554657
Name:BROOKHAVEN GARDENS, LLC
Entity Type:Organization
Organization Name:BROOKHAVEN GARDENS, LLC
Other - Org Name:BROOKHAVEN EXTENSIVE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:P
Authorized Official - Last Name:O'HARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-292-2273
Mailing Address - Street 1:1050 RAMBLING OAKS DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4195
Mailing Address - Country:US
Mailing Address - Phone:405-292-2273
Mailing Address - Fax:405-292-4040
Practice Address - Street 1:1050 RAMBLING OAKS DR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4195
Practice Address - Country:US
Practice Address - Phone:405-292-2273
Practice Address - Fax:405-292-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNH14051405314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375461Medicare ID - Type Unspecified