Provider Demographics
NPI:1740474600
Name:BROOKSIDE CASA ISL
Entity type:Organization
Organization Name:BROOKSIDE CASA ISL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SPOTILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-378-2462
Mailing Address - Street 1:506 BREMOND ST
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:MO
Mailing Address - Zip Code:65084-1122
Mailing Address - Country:US
Mailing Address - Phone:573-378-2462
Mailing Address - Fax:573-378-2462
Practice Address - Street 1:506 BREMOND ST
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084-1122
Practice Address - Country:US
Practice Address - Phone:573-378-2462
Practice Address - Fax:573-378-2462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities