Basic Information
Provider Information
NPI: 1821446444
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BROOKS
FirstName: DESIRAE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10694 HUNTRIDGE RD
Address2:  
City: ORLANDO
State: FL
PostalCode: 328255918
CountryCode: US
TelephoneNumber: 4074966414
FaxNumber:  
Practice Location
Address1: 1000 W BROADWAY ST
Address2: STE 214
City: OVIEDO
State: FL
PostalCode: 327659262
CountryCode: US
TelephoneNumber: 4073595693
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/25/2016
LastUpdateDate: 02/02/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

ID Information
IDTypeStateIssuerDescription
RBT-16-1562401 BACBOTHER


Home