Basic Information
| Provider Information | |||||||||
| NPI: | 1730594029 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROSE | ||||||||
| FirstName: | TEODORA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 131 JONES ST | ||||||||
| Address2: | |||||||||
| City: | APPOMATTOX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245229830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343528235 | ||||||||
| FaxNumber: | 4343525532 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 JONES ST | ||||||||
| Address2: | |||||||||
| City: | APPOMATTOX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4343528235 | ||||||||
| FaxNumber: | 4343525532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2014 | ||||||||
| LastUpdateDate: | 08/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101261264 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 207Q00000X | 01 | VA | FAMILY MEDICINE | OTHER |