1669414926 NPI number — BROOKS HOME CARE ADVANTAGE, INC

Table of content: (NPI 1669414926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669414926 NPI number — BROOKS HOME CARE ADVANTAGE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKS HOME CARE ADVANTAGE, INC
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:
BROOKS AMERICARE HOME HEALTH
Provider Other Organization Name Type Code:
3
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:
1669414926
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3599 UNIVERSITY BLVD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-4252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-345-7607
Provider Business Mailing Address Fax Number:
904-345-7284

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2730 US 1 S STE GANDH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32086-6341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-722-1515
Provider Business Practice Location Address Fax Number:
904-722-1517
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAER
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
904-345-7473

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  299991968 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251E00000X , with the licence number: 299993785 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 299993790 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 299993791 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 299993789 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 299993792 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 299993282 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7144812 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: J9D . This is a "BC/BS PROVIDER NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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