Healthcare Provider Details

I. General information

NPI: 1366939068
Provider Name (Legal Business Name): BROOKSTONE MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 N 100 E
SAINT GEORGE UT
84770-2831
US

IV. Provider business mailing address

198 N 100 E
SAINT GEORGE UT
84770-2831
US

V. Phone/Fax

Practice location:
  • Phone: 435-628-1111
  • Fax:
Mailing address:
  • Phone: 435-628-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number8143132-3102
License Number StateUT

VIII. Authorized Official

Name: MRS. CHRISTINE TIPPETTS BROOKS
Title or Position: PROGRAM DIRECTOR
Credential: RN
Phone: 435-628-1111