Provider Demographics
NPI:1790036713
Name:VICKY BROOKS LLC
Entity Type:Organization
Organization Name:VICKY BROOKS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:847-721-7579
Mailing Address - Street 1:5387 NW PREAKNESS TER
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-8999
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4876 NW BETHANY BLVD
Practice Address - Street 2:L-1
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-9259
Practice Address - Country:US
Practice Address - Phone:847-721-7579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17835225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty