MEDICARE: BRENTWOOD ASSISTED LIVING LLC

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	311500000X	Alzheimer Center (Dementia Center)
2	310400000X	Assisted Living Facility

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	:	1245715507
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENTWOOD ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	915 W AURORA RD
Second Line	:
City	:	SAGAMORE HILLS
State	:	OH
Zip	:	44067-1605
Country	:	US
Telephone Number	:	330-468-2273
Fax Number	:	330-468-0753

Provider Business Practice Location Address
First Line	:	915 W AURORA RD
Second Line	:
City	:	SAGAMORE HILLS
State	:	OH
Zip	:	44067-1605
Country	:	US
Telephone Number	:	330-468-2273
Fax Number	:	330-468-0753

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRENT CLASSEN
Credential	:
Telephone Number	:	330-468-2273

Provider Enumeration Date	:	10/02/2018
Last Update Date	:	10/02/2018

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