Healthcare Provider Details

I. General information

NPI: 1740502756
Provider Name (Legal Business Name): BROOKE MYUNG LM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2010
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 AMY LN
WATERFORD CA
95386-9790
US

IV. Provider business mailing address

509 13TH ST STE 2
MODESTO CA
95354-2444
US

V. Phone/Fax

Practice location:
  • Phone: 209-484-2444
  • Fax:
Mailing address:
  • Phone: 209-521-7981
  • Fax: 209-336-6418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: