1295725455 NPI number — BROOKNEAL LIFE CARE CORP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295725455 NPI number — BROOKNEAL LIFE CARE CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKNEAL LIFE CARE CORP
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:
6
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:
1295725455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3131 ELECTRIC RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-6427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-774-4263
Provider Business Mailing Address Fax Number:
540-774-0780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
633 COOK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKNEAL
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24528-1470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-376-3740
Provider Business Practice Location Address Fax Number:
434-376-3776
Provider Enumeration Date:
10/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GALLANT
Authorized Official First Name:
CASSANDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
COMPLIANCE & PRIVACY OFFICER
Authorized Official Telephone Number:
540-774-4263

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH2571 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4952421 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 227237 . This is a "ANTHEM BCBS HMO PPO ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 608695300 . This is a "FEDERAL BLACK LUNG ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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