Healthcare Provider Details

I. General information

NPI: 1801538376
Provider Name (Legal Business Name): BROOKHAVEN MS OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2022
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 BROOKMAN DR
BROOKHAVEN MS
39601-2384
US

IV. Provider business mailing address

980 SYLVAN AVE
ENGLEWOOD CLIFFS NJ
07632-3301
US

V. Phone/Fax

Practice location:
  • Phone: 601-835-1884
  • Fax:
Mailing address:
  • Phone: 201-928-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: BATYA GORELICK
Title or Position: COO
Credential:
Phone: 201-928-7800