Provider Demographics
NPI:1023064300
Name:BROOKHAVEN HOSPITAL, LLC
Entity type:Organization
Organization Name:BROOKHAVEN HOSPITAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-438-4257
Mailing Address - Street 1:201 S GARNETT RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128-1805
Mailing Address - Country:US
Mailing Address - Phone:918-438-4257
Mailing Address - Fax:918-438-0083
Practice Address - Street 1:201 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128
Practice Address - Country:US
Practice Address - Phone:918-438-4257
Practice Address - Fax:918-438-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2313273Y00000X, 283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100701410AMedicaid
OK100701410CMedicaid
SD0157430Medicaid
NE10026694200Medicaid
WA1023064300Medicaid
KS100299900BMedicaid
OK100701410BMedicaid
AR160837125Medicaid
NM00401269Medicaid
IA0901223Medicaid
TNQ029771Medicaid
NC1023064300Medicaid