Healthcare Provider Details

I. General information

NPI: 1821276510
Provider Name (Legal Business Name): BREA EAST MESA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 N ACADEMY BLVD
COLORADO SPRINGS CO
80917
US

IV. Provider business mailing address

6737 W WASHINGTON ST STE 2300
MILWAUKEE WI
53214-5650
US

V. Phone/Fax

Practice location:
  • Phone: 480-832-1300
  • Fax: 480-638-0841
Mailing address:
  • Phone: 414-918-5000
  • Fax: 206-301-4500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2305S9
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number68533250
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number2305S9
License Number StateCO

VIII. Authorized Official

Name: BRYAN RICHARDSON
Title or Position: EVP, CHIEF ADMIN. OFFICER
Credential:
Phone: 615-564-8131