Provider Demographics
NPI:1245777671
Name:DOH
Entity Type:Organization
Organization Name:DOH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-342-0906
Mailing Address - Street 1:960 ROCKY BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-2706
Mailing Address - Country:US
Mailing Address - Phone:850-342-0906
Mailing Address - Fax:
Practice Address - Street 1:960 ROCKY BRANCH RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-2706
Practice Address - Country:US
Practice Address - Phone:850-342-0906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5226936164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty