Healthcare Provider Details

I. General information

NPI: 1285991158
Provider Name (Legal Business Name): BROOK ASHLEY HEATHCOATE - POWERS CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2012
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 LUCILE AVE STE D
STOCKTON CA
95209-4703
US

IV. Provider business mailing address

1955 LUCILE AVE STE D
STOCKTON CA
95209-4703
US

V. Phone/Fax

Practice location:
  • Phone: 559-381-8645
  • Fax:
Mailing address:
  • Phone: 559-381-8645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number28875
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: