1568657161 NPI number — BROOK HEALTHCARE CORP

Table of content: (NPI 1568657161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568657161 NPI number — BROOK HEALTHCARE CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOK HEALTHCARE 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:
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:
1568657161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 330638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURFREESBORO
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37133-0638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-867-4753
Provider Business Mailing Address Fax Number:
615-867-0177

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
826 MEMORIAL BLVD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
MURFREESBORO
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37129-2738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-867-4753
Provider Business Practice Location Address Fax Number:
615-867-0177
Provider Enumeration Date:
09/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
IKEJIANI
Authorized Official First Name:
TOCHUKWU
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-867-4753

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  34072 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8490876 . This is a "CIGNA HMO" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3886850 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4070446 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: P00035887 . This is a "MADICARE RAILROAD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4089201 . This is a "TENNCARE SELECT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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