MEDICARE: BREA CHARLOTTE, 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	310400000X	Assisted Living Facility	HAL-060-085	NC
2	311500000X	Alzheimer Center (Dementia Center)	HAL-060-085	NC

General Provider Information

NPI Number	:	1306992664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREA CHARLOTTE, LLC

Provider Business Mailing Address
First Line	:	6737 W WASHINGTON ST
Second Line	:	SUITE 2300
City	:	MILWAUKEE
State	:	WI
Zip	:	53214-5647
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5326 PARK RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3648
Country	:	US
Telephone Number	:	704-553-8700
Fax Number	:	704-553-8922

Authorized Official
Title or Position	:	EVP, CHIEF ADMIN. OFFICER
Name	:	BRYAN RICHARDSON
Credential	:
Telephone Number	:	615-564-8131

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	05/16/2016

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