MEDICARE: MR. TRACY CALHOUN BROOKS LOTR

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	225X00000X	Occupational Therapist	Z11700	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ACS PROVIDER NUMBER	OTHER	LA	FED WORK COMP PROVIDER #

General Provider Information

NPI Number	:	1154334902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TRACY CALHOUN BROOKS LOTR

Provider Business Mailing Address
First Line	:	2409 ARKANSAS RD
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71291-8611
Country	:	US
Telephone Number	:	318-396-2044
Fax Number	:	318-396-2204

Provider Business Practice Location Address
First Line	:	2409 ARKANSAS RD
Second Line	:
City	:	WEST MONROE
State	:	LA
Zip	:	71291-8611
Country	:	US
Telephone Number	:	318-396-2044
Fax Number	:	318-396-2204

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

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	07/08/2007

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