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General NPI Number Information
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NPI Number | 1528834207
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Entity Type | Organization
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Legal Business Name | BROOKESIDE LLC
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Dates
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Enumeration Date | 12/04/2023
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Last Update Date | 12/04/2023
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Provider Practice Location Address
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Address Line | 80 ACOMA BLVD S STE 104&106
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-6925
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Country | US
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Telephone | 928-453-1055
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Fax |
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Provider Business Mailing Address
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Address Line | 2827 SARATOGA AVE
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86406-6956
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Country | US
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Telephone | 971-273-9432
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Fax | 928-224-1775
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Authorized Official
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Title or Position | OWNER/MASSAGE THERAPIST
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Name | BROOKE NICHOLE FOLTZ
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Credential | LMT
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Telephone | 971-273-9432
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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