MEDICARE: BROOKSIDE CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3104A0625X	Assisted Living Facility (Mental Illness)

General Provider Information

NPI Number	:	1134558455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKSIDE CARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 244
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49004-0244
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5078 SOLVEL ST
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49004-1915
Country	:	US
Telephone Number	:	269-373-3842
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ADAM FRAZIER
Credential	:
Telephone Number	:	269-373-3842

Provider Enumeration Date	:	11/06/2013
Last Update Date	:	11/06/2013

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