Provider Demographics
NPI:1679943419
Name:BROOKS, PORTIA
Entity type:Individual
Prefix:
First Name:PORTIA
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 1:5880 RIVERS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-6053
Mailing Address - Country:US
Mailing Address - Phone:843-725-4673
Mailing Address - Fax:843-725-1235
Practice Address - Street 1:5880 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-6053
Practice Address - Country:US
Practice Address - Phone:843-725-4673
Practice Address - Fax:843-725-1235
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other