Healthcare Provider Details

I. General information

NPI: 1134926769
Provider Name (Legal Business Name): BROOM HOMESTEAD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2025
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3616 10TH AVE
LOS ANGELES CA
90018-4113
US

IV. Provider business mailing address

3616 10TH AVE
LOS ANGELES CA
90018-4113
US

V. Phone/Fax

Practice location:
  • Phone: 323-643-4869
  • Fax: 323-643-4869
Mailing address:
  • Phone: 323-643-4869
  • Fax: 323-643-4869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. WALTER E BROOM
Title or Position: CEO/EXECUTIVE DIRECTOR
Credential: CADC II
Phone: 323-643-4869