Healthcare Provider Details

I. General information

NPI: 1730594029
Provider Name (Legal Business Name): TEODORA BROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 JONES ST
APPOMATTOX VA
24522
US

IV. Provider business mailing address

131 JONES ST
APPOMATTOX VA
24522-9830
US

V. Phone/Fax

Practice location:
  • Phone: 434-352-8235
  • Fax: 434-352-5532
Mailing address:
  • Phone: 434-352-8235
  • Fax: 434-352-5532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101261264
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: