1689792418 NPI number — BROOKE VITA TOWNSEND AUD, CCC-A

Table of content: BROOKE VITA TOWNSEND AUD, CCC-A (NPI 1689792418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689792418 NPI number — BROOKE VITA TOWNSEND AUD, CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOWNSEND
Provider First Name:
BROOKE
Provider Middle Name:
VITA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AUD, CCC-A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ABBOTT
Provider Other First Name:
BROOKE
Provider Other Middle Name:
VITA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AUD, CCC-A
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689792418
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
744 CORAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE CORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33904-5901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-542-6732
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9732 COMMERCE CENTER CT
Provider Second Line Business Practice Location Address:
UNIT A
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33908-3647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-332-0707
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  AY1113 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: S9121 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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