MEDICARE: BRENTWOOD HEALTHCARE ENTERPRISES

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1770813115
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENTWOOD HEALTHCARE ENTERPRISES

Provider Business Mailing Address
First Line	:	907 W AURORA RD
Second Line	:
City	:	SAGAMORE HILLS
State	:	OH
Zip	:	44067-1605
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	907 W AURORA RD
Second Line	:
City	:	SAGAMORE HILLS
State	:	OH
Zip	:	44067-1605
Country	:	US
Telephone Number	:	330-468-2273
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL B CLASSEN
Credential	:
Telephone Number	:	330-468-2273

Provider Enumeration Date	:	01/07/2010
Last Update Date	:	01/07/2010

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