=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932518909
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BROOKHURST RESIDENTIAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2014
-----------------------------------------------------
Last Update Date | 08/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9925 LA ALAMEDA AVE
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-3548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-962-5531
-----------------------------------------------------
Fax | 818-638-5769
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9925 LA ALAMEDA AVE
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-3548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-962-5531
-----------------------------------------------------
Fax | 818-638-5769
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | KAROLINA MARIA FIL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-962-5531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 306004415
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------