Provider Demographics
NPI:1790758423
Name:BROOKVILLE ENTERPRISE INC.
Entity Type:Organization
Organization Name:BROOKVILLE ENTERPRISE INC.
Other - Org Name:BROOKHAVEN NURSING CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCKINNISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-833-2133
Mailing Address - Street 1:1 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45309-9269
Mailing Address - Country:US
Mailing Address - Phone:937-833-2133
Mailing Address - Fax:
Practice Address - Street 1:1 COUNTRY LN
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:OH
Practice Address - Zip Code:45309-9269
Practice Address - Country:US
Practice Address - Phone:937-833-2133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4590314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0406484Medicaid
OH365422Medicare ID - Type Unspecified