Healthcare Provider Details

I. General information

NPI: 1083657902
Provider Name (Legal Business Name): ANDY THOMAS BROOKS R.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ANDY THOMAS BROOKS R.D.

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1989 OAK TREE CV STE B
HERNANDO MS
38632-1536
US

IV. Provider business mailing address

1989 OAK TREE CV STE B
HERNANDO MS
38632-1536
US

V. Phone/Fax

Practice location:
  • Phone: 901-488-0681
  • Fax:
Mailing address:
  • Phone: 901-488-0681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD0908
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: