Healthcare Provider Details

I. General information

NPI: 1770118622
Provider Name (Legal Business Name): BROOKE GACEK RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BROOKE FISHER RDN, LD

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 AIRPORT BLVD STE A101
MOBILE AL
36608-6767
US

IV. Provider business mailing address

2889 SOLLIE RD APT 303
MOBILE AL
36695-5535
US

V. Phone/Fax

Practice location:
  • Phone: 251-633-8880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3114
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: