Provider Demographics
NPI:1679848303
Name:BROOKS, DAVE (LMP)
Entity Type:Individual
Prefix:MR
First Name:DAVE
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7636 RIXIE ST SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-5668
Mailing Address - Country:US
Mailing Address - Phone:360-485-2338
Mailing Address - Fax:
Practice Address - Street 1:3912 MARTIN WAY E STE A
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5220
Practice Address - Country:US
Practice Address - Phone:360-485-2338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60225476174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist