Provider Demographics
NPI:1952672578
Name:BROOKSGATE INC.
Entity Type:Organization
Organization Name:BROOKSGATE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN, CDE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD, CDE
Authorized Official - Phone:806-252-1507
Mailing Address - Street 1:PO BOX 16881
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79490-6881
Mailing Address - Country:US
Mailing Address - Phone:806-252-1507
Mailing Address - Fax:806-785-4929
Practice Address - Street 1:6829 6TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-3769
Practice Address - Country:US
Practice Address - Phone:806-252-1507
Practice Address - Fax:806-785-4929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07317133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D3218OtherMEDICARE ID - TYPE UNSPECIFIED
TXQ38462Medicare UPIN