Provider Demographics
NPI:1992544209
Name:BRAYBROOK RESIDENCE ALF LLC
Entity type:Organization
Organization Name:BRAYBROOK RESIDENCE ALF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAMBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-543-8109
Mailing Address - Street 1:3087 SUNCOAST BLEND DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-2780
Mailing Address - Country:US
Mailing Address - Phone:727-543-8109
Mailing Address - Fax:
Practice Address - Street 1:7532 STATE ROAD 52
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-6715
Practice Address - Country:US
Practice Address - Phone:727-863-3580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility