1275093585 NPI number — BROOKDALE DRUG & ALCOHOL REHABILITATION CENTER LLC

Table of content: (NPI 1275093585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275093585 NPI number — BROOKDALE DRUG & ALCOHOL REHABILITATION CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKDALE DRUG & ALCOHOL REHABILITATION CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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NPI Number Information

NPI Number:
1275093585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18401 VON KARMAN AVE STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92612-8531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-828-1800
Provider Business Mailing Address Fax Number:
714-882-1186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2455 BACK MOUNTAIN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOTRUN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-828-1800
Provider Business Practice Location Address Fax Number:
714-882-1186
Provider Enumeration Date:
03/22/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GUSTILO
Authorized Official First Name:
MAGDALEN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PAYER RELATIONS
Authorized Official Telephone Number:
714-568-7667

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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