Provider Demographics
NPI:1679710099
Name:BROOKDALE SENIOR LIVING
Entity Type:Organization
Organization Name:BROOKDALE SENIOR LIVING
Other - Org Name:WEDDINGTON PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:AVERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-847-9477
Mailing Address - Street 1:2404 PLANTATION CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5299
Mailing Address - Country:US
Mailing Address - Phone:704-847-9477
Mailing Address - Fax:704-814-9869
Practice Address - Street 1:2404 PLANTATION CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5299
Practice Address - Country:US
Practice Address - Phone:704-847-9477
Practice Address - Fax:704-814-9869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-060-042310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility