Healthcare Provider Details

I. General information

NPI: 1497750954
Provider Name (Legal Business Name): BROOKSVILLE HEALTH CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 CHATMAN BLVD
BROOKSVILLE FL
34601-3104
US

IV. Provider business mailing address

1114 CHATMAN BLVD
BROOKSVILLE FL
34601-3104
US

V. Phone/Fax

Practice location:
  • Phone: 352-796-6701
  • Fax: 352-796-6514
Mailing address:
  • Phone: 352-796-6701
  • Fax: 352-796-6514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF 1063096
License Number StateFL

VIII. Authorized Official

Name: MS. WANDA MOAK
Title or Position: ADMINISTRATOR
Credential:
Phone: 352-796-6701