Healthcare Provider Details

I. General information

NPI: 1013901917
Provider Name (Legal Business Name): BROOKSIDE NURSING HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 06/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHRISTIAN ST
WHITE RIVER JCT VT
05001
US

IV. Provider business mailing address

1200 CHRISTIAN ST
WHITE RIVER JCT VT
05001
US

V. Phone/Fax

Practice location:
  • Phone: 802-295-7511
  • Fax: 802-295-2533
Mailing address:
  • Phone: 802-295-7511
  • Fax: 802-295-2533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0270000136
License Number StateVT

VIII. Authorized Official

Name: MR. THOMAS E RICE SR.
Title or Position: PRESIDENT ADMINISTRATOR
Credential: ADMINISTRATOR
Phone: 802-295-7511