Healthcare Provider Details

I. General information

NPI: 1942018833
Provider Name (Legal Business Name): BROOKHAVEN MS OPERATING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 BROOKMAN DR
BROOKHAVEN MS
39601-2384
US

IV. Provider business mailing address

710 OBRECHT RD
SYKESVILLE MD
21784-7650
US

V. Phone/Fax

Practice location:
  • Phone: 601-835-1884
  • Fax:
Mailing address:
  • Phone:
  • 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: MOISHE MAYER
Title or Position: AUTHORIZED SIGNATORY
Credential:
Phone: 718-614-8341