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General NPI Number Information
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NPI Number | 1508035817
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Entity Type | Organization
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Legal Business Name | CHARLES W. BROOKS, O.D., P.C.
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Dates
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Enumeration Date | 02/21/2008
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Last Update Date | 02/21/2008
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Provider Practice Location Address
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Address Line | 201 S ABILENE AVE
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City | PORTALES
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State | NM
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Zip | 88130-6207
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Country | US
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Telephone | 575-359-1252
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Fax | 575-359-2601
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Provider Business Mailing Address
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Address Line | 201 S ABILENE AVE
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City | PORTALES
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State | NM
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Zip | 88130-6207
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Country | US
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Telephone | 575-359-1252
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Fax | 575-359-2601
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHARLES W. BROOKS
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Credential | O.D.
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Telephone | 575-359-1252
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2292
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License Number State | NM
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