=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497750954
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKSVILLE HEALTH CARE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2005
-----------------------------------------------------
Last Update Date | 02/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1114 CHATMAN BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34601-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-796-6701
-----------------------------------------------------
Fax | 352-796-6514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1114 CHATMAN BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34601-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-796-6701
-----------------------------------------------------
Fax | 352-796-6514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. WANDA MOAK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-796-6701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | SNF 1063096
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------