MEDICARE: BROOM HOMESTEAD INC

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	320800000X	Mental Illness Community Based Residential Treatment Facility
2	171M00000X	Case Manager/Care Coordinator

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B1305161051	OTHER	CA	SUBSTANCE/ADDICTION COUNSELOR

General Provider Information

NPI Number	:	1134926769
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOM HOMESTEAD INC

Provider Business Mailing Address
First Line	:	3616 10TH AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90018-4113
Country	:	US
Telephone Number	:	323-643-4869
Fax Number	:	323-643-4869

Provider Business Practice Location Address
First Line	:	3616 10TH AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90018-4113
Country	:	US
Telephone Number	:	323-643-4869
Fax Number	:	323-643-4869

Authorized Official
Title or Position	:	CEO/EXECUTIVE DIRECTOR
Name	:	MR. WALTER E BROOM
Credential	:	CADC II
Telephone Number	:	323-643-4869

Provider Enumeration Date	:	03/01/2025
Last Update Date	:	04/02/2025

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Directions to “BROOM HOMESTEAD INC ” Practice Location

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