Provider Demographics
NPI:1639344898
Name:BROADWATER COMMUNITY CARE CENTER, LLC
Entity type:Organization
Organization Name:BROADWATER COMMUNITY CARE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:EASTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-308-7191
Mailing Address - Street 1:2335 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-3559
Mailing Address - Country:US
Mailing Address - Phone:626-357-3207
Mailing Address - Fax:626-303-1113
Practice Address - Street 1:2335 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-3559
Practice Address - Country:US
Practice Address - Phone:626-357-3207
Practice Address - Fax:626-303-1113
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARKSTONE HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950000051314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05A109Medicare Oscar/Certification