Healthcare Provider Details

I. General information

NPI: 1508292582
Provider Name (Legal Business Name): BRENTWOOD MEADOWS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4488 ROSLIN RD
NEWBURGH IN
47630-8590
US

IV. Provider business mailing address

4488 ROSLIN RD
NEWBURGH IN
47630-8590
US

V. Phone/Fax

Practice location:
  • Phone: 812-858-7200
  • Fax:
Mailing address:
  • Phone: 812-858-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number71003322A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01043877A
License Number StateIN

VIII. Authorized Official

Name: MS. DONNA SALEE WEST
Title or Position: DIRECTOR OF LICENSE AND REGULATION
Credential: RN
Phone: 812-598-8989