Provider Demographics
NPI:1245715507
Name:BRENTWOOD ASSISTED LIVING LLC
Entity type:Organization
Organization Name:BRENTWOOD ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:CLASSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-468-2273
Mailing Address - Street 1:915 W AURORA RD
Mailing Address - Street 2:
Mailing Address - City:SAGAMORE HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44067-1605
Mailing Address - Country:US
Mailing Address - Phone:330-468-2273
Mailing Address - Fax:330-468-0753
Practice Address - Street 1:915 W AURORA RD
Practice Address - Street 2:
Practice Address - City:SAGAMORE HILLS
Practice Address - State:OH
Practice Address - Zip Code:44067-1605
Practice Address - Country:US
Practice Address - Phone:330-468-2273
Practice Address - Fax:330-468-0753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0313053Medicaid