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General NPI Number Information
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NPI Number | 1245777671
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Entity Type | Organization
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Legal Business Name | DOH
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Dates
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Enumeration Date | 01/24/2017
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Last Update Date | 01/24/2017
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Provider Practice Location Address
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Address Line | 960 ROCKY BRANCH RD
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City | MONTICELLO
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State | FL
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Zip | 32344-2706
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Country | US
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Telephone | 850-342-0906
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Fax |
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Provider Business Mailing Address
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Address Line | 960 ROCKY BRANCH RD
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City | MONTICELLO
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State | FL
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Zip | 32344-2706
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Country | US
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Telephone | 850-342-0906
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Fax |
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Authorized Official
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Title or Position | LPN
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Name | JAMIE BROCKMAN
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Credential |
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Telephone | 850-342-0906
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | PN5226936
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License Number State | FL
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