1013056563 NPI number — BROOKSIDE SERVICES, PLLC

Table of content: (NPI 1013056563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013056563 NPI number — BROOKSIDE SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKSIDE SERVICES, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013056563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 430355
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONTIAC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48343-0355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-390-5919
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 E IROQUOIS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONTIAC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48341-2016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-390-5919
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WASHINGTON
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
JOYCE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-390-5919

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  6801073653 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: $$$$$$$$$ . This is a "SSN OF SOLE PROPRIETOR" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 6801073653 . This is a "STATE CLINICAL LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com