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General NPI Number Information
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NPI Number | 1558329185
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Entity Type | Organization
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Legal Business Name | BROOKSIDE CARE CENTER
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Dates
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Enumeration Date | 05/03/2006
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Last Update Date | 02/05/2008
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Provider Practice Location Address
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Address Line | 3506 WASHINGTON RD
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City | KENOSHA
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State | WI
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Zip | 53144
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Country | US
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Telephone | 262-653-3800
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Fax | 262-653-3850
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Provider Business Mailing Address
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Address Line | 3506 WASHINGTON RD
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City | KENOSHA
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State | WI
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Zip | 53144
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Country | US
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Telephone | 262-653-3800
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Fax | 262-653-3850
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | SANDRA HARDT
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Credential | NHA RN
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Telephone | 262-653-3800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 3155
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License Number State | WI
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