=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316154529
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL RUTH BROWN LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 S 2ND ST UNIT 2
-----------------------------------------------------
City | FLAGLER BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32136-6603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-493-6715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 209 S 2ND ST UNIT 2
-----------------------------------------------------
City | FLAGLER BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32136-6603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-493-6715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA26253
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------