Healthcare Provider Details

I. General information

NPI: 1225654494
Provider Name (Legal Business Name): BROOKS - TLC HOSPITAL SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7020 ERIE ROAD
DERBY NY
14047
US

IV. Provider business mailing address

529 CENTRAL AVE
DUNKIRK NY
14048-2514
US

V. Phone/Fax

Practice location:
  • Phone: 716-947-0316
  • Fax:
Mailing address:
  • Phone: 716-366-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: MARY ELIZABETH LAROWE
Title or Position: PRESIDENT & CEO
Credential:
Phone: 716-363-7207