1568535474 NPI number — BROOKDALE CLINIC

Table of content: (NPI 1568535474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568535474 NPI number — BROOKDALE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKDALE CLINIC
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:
1568535474
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:
2717 N GRANDVIEW BLVD
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
WAUKESHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-513-0700
Provider Business Mailing Address Fax Number:
262-513-0707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20700 WATERTOWN RD
Provider Second Line Business Practice Location Address:
STE 206
Provider Business Practice Location Address City Name:
WAUKESHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-513-0700
Provider Business Practice Location Address Fax Number:
262-513-0707
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HADAR
Authorized Official First Name:
ILANA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
262-717-0077

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  904 057 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com