Healthcare Provider Details

I. General information

NPI: 1760400378
Provider Name (Legal Business Name): BROOKS FARRY MS, ATC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 FOREST STREET ATHLETIC TRAINING DEPARTMENT
WALTHAM MA
02452
US

IV. Provider business mailing address

11 BRANDLEY RD
WATERTOWN MA
02472-2217
US

V. Phone/Fax

Practice location:
  • Phone: 781-891-2062
  • Fax:
Mailing address:
  • Phone: 781-891-2062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number403
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: