MEDICARE: KEANTHONY DARNELL BROOKS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1043895568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEANTHONY DARNELL BROOKS

Provider Business Mailing Address
First Line	:	31 HICKORY HEIGHTS DR
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36870-2396
Country	:	US
Telephone Number	:	229-514-8752
Fax Number	:

Provider Business Practice Location Address
First Line	:	31 HICKORY HEIGHTS DR
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36870-2396
Country	:	US
Telephone Number	:	229-514-8752
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2021
Last Update Date	:	03/16/2021

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