MEDICARE: JAMES MICHAEL BROCKWELL RD

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	133V00000X	Registered Dietitian	ND8316	FL

General Provider Information

NPI Number	:	1477060317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES MICHAEL BROCKWELL RD

Provider Business Mailing Address
First Line	:	1603 N PALM DR
Second Line	:
City	:	AVON PARK
State	:	FL
Zip	:	33825-2127
Country	:	US
Telephone Number	:	863-873-1988
Fax Number	:

Provider Business Practice Location Address
First Line	:	1603 N PALM DR
Second Line	:
City	:	AVON PARK
State	:	FL
Zip	:	33825-2127
Country	:	US
Telephone Number	:	863-873-1988
Fax Number	:

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

Provider Enumeration Date	:	12/31/2017
Last Update Date	:	12/31/2017

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