Healthcare Provider Details

I. General information

NPI: 1245043736
Provider Name (Legal Business Name): BROOKSIDE ACADEMY BUSINESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2025
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29910 HUNTER RD STE 104
MURRIETA CA
92563-2763
US

IV. Provider business mailing address

11201 OUTLOOK ST APT 4275
OVERLAND PARK KS
66211-1989
US

V. Phone/Fax

Practice location:
  • Phone: 951-304-7777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN COMER
Title or Position: OWNER
Credential:
Phone: 951-230-6651