Provider Demographics
NPI:1366224065
Name:BROOKSIDE HEALTH INITIATIVES
Entity type:Organization
Organization Name:BROOKSIDE HEALTH INITIATIVES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LENDOL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-443-9595
Mailing Address - Street 1:1902 S IH 35
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-3628
Mailing Address - Country:US
Mailing Address - Phone:512-443-9595
Mailing Address - Fax:512-443-7077
Practice Address - Street 1:1902 S IH 35
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-3628
Practice Address - Country:US
Practice Address - Phone:512-443-9595
Practice Address - Fax:512-443-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-17
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty