Provider Demographics
NPI:1811694730
Name:BROOKS MANOR LLC
Entity type:Organization
Organization Name:BROOKS MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:DEVINDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERSAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-607-3858
Mailing Address - Street 1:2043 SE WATERCREST ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-4768
Mailing Address - Country:US
Mailing Address - Phone:772-607-3858
Mailing Address - Fax:
Practice Address - Street 1:2043 SE WATERCREST ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-4768
Practice Address - Country:US
Practice Address - Phone:772-607-3858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-10
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility