MEDICARE: MR. MARK BROOKS NURSING ASSISTANT

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	376K00000X	Nurse's Aide	401091190510	OH

General Provider Information

NPI Number	:	1306140124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK BROOKS NURSING ASSISTANT

Provider Business Mailing Address
First Line	:	4438 DONNA DR
Second Line	:
City	:	RICHMOND HEIGHTS
State	:	OH
Zip	:	44143-2630
Country	:	US
Telephone Number	:	216-440-2352
Fax Number	:

Provider Business Practice Location Address
First Line	:	4438 DONNA DR
Second Line	:
City	:	RICHMOND HEIGHTS
State	:	OH
Zip	:	44143-2630
Country	:	US
Telephone Number	:	216-440-2352
Fax Number	:

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

Provider Enumeration Date	:	01/09/2011
Last Update Date	:	01/09/2011

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