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General NPI Number Information
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NPI Number | 1417440488
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Entity Type | Organization
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Legal Business Name | BROOKE HAVEN CARE HOME LLC
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Dates
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Enumeration Date | 06/13/2018
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1540 BERCKMANS RD
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City | FORT WORTH
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State | TX
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Zip | 76120-1500
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Country | US
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Telephone | 817-308-1806
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Fax |
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Provider Business Mailing Address
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Address Line | 4009 COTTAGE PARK CT
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City | ARLINGTON
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State | TX
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Zip | 76013-8087
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Country | US
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Telephone | 817-308-1806
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Fax |
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Authorized Official
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Title or Position | SPECIALIST
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Name | MR. TYRIN HOLT
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Credential |
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Telephone | 817-308-1806
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State | TX
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