Provider Demographics
NPI:1568241891
Name:BROOKS, EPHESUS
Entity Type:Individual
Prefix:
First Name:EPHESUS
Middle Name:
Last Name:BROOKS
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 1:4445 CORPORATION LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3262
Mailing Address - Country:US
Mailing Address - Phone:804-972-1132
Mailing Address - Fax:
Practice Address - Street 1:2801 PENNINGTON RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-4013
Practice Address - Country:US
Practice Address - Phone:804-418-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X, 3747P1801X, 226000000X, 374U00000X, 247000000X, 171M00000X
VAT67133866172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor
No172A00000XOther Service ProvidersDriver
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No226000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreational Therapist Assistant
No374U00000XNursing Service Related ProvidersHome Health Aide
No247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information