Provider Demographics
NPI:1699001420
Name:BREA SMYRNA LLC
Entity type:Organization
Organization Name:BREA SMYRNA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:NOELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BICKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-298-2909
Mailing Address - Street 1:3131 ELLIOTT AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-1032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4375 BEECH HAVEN TRL SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6601
Practice Address - Country:US
Practice Address - Phone:770-803-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BREA EMERITUS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033-03-022-1311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)