Healthcare Provider Details

I. General information

NPI: 1174859904
Provider Name (Legal Business Name): BREA DECATUR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 IRVIN CT
DECATUR GA
30030-1717
US

IV. Provider business mailing address

3131 ELLIOTT AVE STE 500
SEATTLE WA
98121-1032
US

V. Phone/Fax

Practice location:
  • Phone: 404-299-6600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number044-03-241
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number044-03-241
License Number StateGA

VIII. Authorized Official

Name: NOELLE BICKEL
Title or Position: LICENSING SPECIALIST
Credential:
Phone: 206-298-2909