Provider Demographics
NPI:1689863185
Name:BROOKS, TORINA LATERRAL
Entity Type:Individual
Prefix:MS
First Name:TORINA
Middle Name:LATERRAL
Last Name:BROOKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W 58TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-4140
Mailing Address - Country:US
Mailing Address - Phone:904-894-4451
Mailing Address - Fax:904-765-4544
Practice Address - Street 1:450 W 58TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-4140
Practice Address - Country:US
Practice Address - Phone:904-894-4451
Practice Address - Fax:904-765-4544
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11105177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging