MEDICARE: BROOKHAVEN'S RESIDENTIAL CARE CENTER

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	163W00000X	Registered Nurse	118746	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	228014	OTHER	TX	TX BOARD OF NURSE EXAM

General Provider Information

NPI Number	:	1124167895
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKHAVEN'S RESIDENTIAL CARE CENTER

Provider Business Mailing Address
First Line	:	1222 THERESA ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77051
Country	:	US
Telephone Number	:	713-738-6077
Fax Number	:	713-264-0477

Provider Business Practice Location Address
First Line	:	1222 THERESA ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77051
Country	:	US
Telephone Number	:	713-738-6077
Fax Number	:	713-264-0477

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	FLORINE MELTON
Credential	:	RN
Telephone Number	:	713-738-6077

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	08/22/2020

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