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General NPI Number Information
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NPI Number | 1134926769
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Entity Type | Organization
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Legal Business Name | BROOM HOMESTEAD INC
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Dates
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Enumeration Date | 03/01/2025
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Last Update Date | 04/02/2025
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Provider Practice Location Address
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Address Line | 3616 10TH AVE
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City | LOS ANGELES
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State | CA
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Zip | 90018-4113
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Country | US
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Telephone | 323-643-4869
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Fax | 323-643-4869
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Provider Business Mailing Address
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Address Line | 3616 10TH AVE
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City | LOS ANGELES
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State | CA
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Zip | 90018-4113
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Country | US
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Telephone | 323-643-4869
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Fax | 323-643-4869
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Authorized Official
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Title or Position | CEO/EXECUTIVE DIRECTOR
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Name | MR. WALTER E BROOM
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Credential | CADC II
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Telephone | 323-643-4869
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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