Provider Demographics
NPI:1821276510
Name:BREA EAST MESA, LLC
Entity Type:Organization
Organization Name:BREA EAST MESA, LLC
Other - Org Name:BROOKDALE PALMER PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP, CHIEF ADMIN. OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-564-8131
Mailing Address - Street 1:6737 W WASHINGTON ST STE 2300
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-5650
Mailing Address - Country:US
Mailing Address - Phone:414-918-5000
Mailing Address - Fax:206-301-4500
Practice Address - Street 1:2850 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917
Practice Address - Country:US
Practice Address - Phone:480-832-1300
Practice Address - Fax:480-638-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2305S9310400000X, 311500000X
CO68533250310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO205629Medicaid
CO79559301Medicaid
00000OtherPRIVATE