Provider Demographics
NPI:1053183632
Name:BREWSTER PARKE ASSISTED LIVING
Entity type:Organization
Organization Name:BREWSTER PARKE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-767-7435
Mailing Address - Street 1:360 WABASH AVE N
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44613-1042
Mailing Address - Country:US
Mailing Address - Phone:330-767-4179
Mailing Address - Fax:
Practice Address - Street 1:360 WABASH AVE N
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:OH
Practice Address - Zip Code:44613-1042
Practice Address - Country:US
Practice Address - Phone:330-767-3451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BREWSTER PARKE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-26
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2784RMedicaid