MEDICARE: LACIE L BROWN PT

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	225100000X	Physical Therapist	008964	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	008964	OTHER	GA	PHYSICAL THERAPY LISC#

General Provider Information

NPI Number	:	1114060407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACIE L BROWN PT

Provider Business Mailing Address
First Line	:	PO BOX 949
Second Line	:
City	:	ROME
State	:	GA
Zip	:	30162-0949
Country	:	US
Telephone Number	:	706-802-1991
Fax Number	:	706-802-1408

Provider Business Practice Location Address
First Line	:	4204 CORAL PARK DR
Second Line	:
City	:	BRUNSWICK
State	:	GA
Zip	:	31520-3016
Country	:	US
Telephone Number	:	912-280-9205
Fax Number	:	912-280-0022

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	04/17/2009

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Directions to “ LACIE L BROWN PT” Practice Location

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