MEDICARE: BROOKHAVEN NURSING HOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	1048	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043200454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKHAVEN NURSING HOME

Provider Business Mailing Address
First Line	:	813 4TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4422
Country	:	US
Telephone Number	:	505-425-9304
Fax Number	:	505-425-9305

Provider Business Practice Location Address
First Line	:	813 4TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4422
Country	:	US
Telephone Number	:	505-425-9304
Fax Number	:	505-425-9305

Authorized Official
Title or Position	:	MANAGER OF OPERATIONS
Name	:	MRS. VICTORIA ARAGON
Credential	:
Telephone Number	:	505-425-9304

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	08/22/2020

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