Provider Demographics
NPI:1104215904
Name:BROWN, KASIB
Entity Type:Individual
Prefix:
First Name:KASIB
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 VIZCAYA LAKES RD APT 310
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-6902
Mailing Address - Country:US
Mailing Address - Phone:727-278-3102
Mailing Address - Fax:
Practice Address - Street 1:1036 VIZCAYA LAKES RD APT 310
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-6902
Practice Address - Country:US
Practice Address - Phone:727-278-3102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL2794172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker