Provider Demographics
NPI:1104303411
Name:BROOKYS HAVEN
Entity type:Organization
Organization Name:BROOKYS HAVEN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-423-1367
Mailing Address - Street 1:217 JONES ST APT 215
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4060
Mailing Address - Country:US
Mailing Address - Phone:131-842-3136
Mailing Address - Fax:
Practice Address - Street 1:217 JONES ST APT 215
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4060
Practice Address - Country:US
Practice Address - Phone:131-842-3136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No251G00000XAgenciesHospice Care, Community BasedGroup - Single Specialty