MEDICARE: CHRISTINE BROOKS CHARLESTON 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	86043508	CO

General Provider Information

NPI Number	:	1538886536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE BROOKS CHARLESTON RD

Provider Business Mailing Address
First Line	:	PO BOX 1189
Second Line	:
City	:	FRISCO
State	:	CO
Zip	:	80443-1189
Country	:	US
Telephone Number	:	303-345-5941
Fax Number	:

Provider Business Practice Location Address
First Line	:	6156 ROCKVILLE DRIVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923
Country	:	US
Telephone Number	:	303-345-5941
Fax Number	:

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

Provider Enumeration Date	:	10/20/2022
Last Update Date	:	10/21/2022

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