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General NPI Number Information
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NPI Number | 1144563222
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Entity Type | Organization
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Legal Business Name | SL GLENBROOKE LLC
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Dates
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Enumeration Date | 03/27/2013
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Last Update Date | 03/27/2013
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Provider Practice Location Address
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Address Line | 815 BRIAR CREEK BLVD NE
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City | PALM BAY
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State | FL
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Zip | 32905-5423
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Country | US
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Telephone | 321-956-3330
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Fax | 321-956-3998
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Provider Business Mailing Address
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Address Line | 815 BRIAR CREEK BLVD NE
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City | PALM BAY
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State | FL
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Zip | 32905-5423
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Country | US
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Telephone | 321-956-3330
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Fax | 321-956-3998
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. CHARLOTTE WILLIS
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Credential | LCSW
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Telephone | 321-956-3330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL11650
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License Number State | FL
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