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General NPI Number Information
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NPI Number | 1790036713
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Entity Type | Organization
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Legal Business Name | VICKY BROOKS LLC
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Dates
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Enumeration Date | 10/01/2012
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Last Update Date | 07/24/2014
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Provider Practice Location Address
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Address Line | 4876 NW BETHANY BLVD L-1
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City | PORTLAND
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State | OR
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Zip | 97229-9259
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Country | US
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Telephone | 847-721-7579
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Fax |
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Provider Business Mailing Address
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Address Line | 5387 NW PREAKNESS TER
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City | PORTLAND
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State | OR
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Zip | 97229-8999
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MASSAGE THERAPIST
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Name | MRS. VICKY BROOKS
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Credential | L.M.T.
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Telephone | 847-721-7579
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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 | 17835
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License Number State | OR
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