Provider Demographics
NPI:1053797407
Name:BROOKS, KACI
Entity type:Individual
Prefix:
First Name:KACI
Middle Name:
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 1:2928 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45403-1215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2928 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45403-1215
Practice Address - Country:US
Practice Address - Phone:937-607-3058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-08
Last Update Date:2015-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4005398609063747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant