Provider Demographics
NPI:1528834207
Name:BROOKESIDE LLC
Entity type:Organization
Organization Name:BROOKESIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:NICHOLE
Authorized Official - Last Name:FOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:971-273-9432
Mailing Address - Street 1:2827 SARATOGA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-6956
Mailing Address - Country:US
Mailing Address - Phone:971-273-9432
Mailing Address - Fax:928-224-1775
Practice Address - Street 1:80 ACOMA BLVD S STE 104&106
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6925
Practice Address - Country:US
Practice Address - Phone:928-453-1055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1326770363Medicaid