MEDICARE: MR. TAYLOR BROOKS DOUGLAS RBT

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	247200000X	Other Technician

General Provider Information

NPI Number	:	1053729889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TAYLOR BROOKS DOUGLAS RBT

Provider Business Mailing Address
First Line	:	35 VILLAGE DR
Second Line	:
City	:	FLAGLER BEACH
State	:	FL
Zip	:	32136-3484
Country	:	US
Telephone Number	:	386-569-3346
Fax Number	:

Provider Business Practice Location Address
First Line	:	515 PALM COAST PKWY SW
Second Line	:	SUITE 6/7
City	:	PALM COAST
State	:	FL
Zip	:	32137-4739
Country	:	US
Telephone Number	:	386-951-3044
Fax Number	:	866-610-0580

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

Provider Enumeration Date	:	07/24/2014
Last Update Date	:	08/19/2016

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