Provider Demographics
NPI:1477127389
Name:PEAKLIFE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:PEAKLIFE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TAVARIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:850-525-9684
Mailing Address - Street 1:101 PALAFOX PL # 13132
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-5629
Mailing Address - Country:US
Mailing Address - Phone:850-525-9684
Mailing Address - Fax:
Practice Address - Street 1:9 W BLOUNT ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2614
Practice Address - Country:US
Practice Address - Phone:850-525-9684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-14
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty