Basic Information
| Provider Information | |||||||||
| NPI: | 1518404078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHERINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 NE COURT ST | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977541936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413235330 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1251 NE ELM ST | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977541206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413235330 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2017 | ||||||||
| LastUpdateDate: | 01/23/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | N | 175T00000X | OR | Y |
ID Information
| ID | Type | State | Issuer | Description | 283234 | 05 | OR | MEDICAID |