Provider Demographics
NPI:1124772900
Name:BROOKS, GREGORY ALLEN SR
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
Last Name:BROOKS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17932 BELLINGRATH LAKES AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWELL SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70739-4758
Mailing Address - Country:US
Mailing Address - Phone:225-276-5966
Mailing Address - Fax:
Practice Address - Street 1:17932 BELLINGRATH LAKES AVE
Practice Address - Street 2:
Practice Address - City:GREENWELL SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70739-4758
Practice Address - Country:US
Practice Address - Phone:225-276-5966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA830628343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA88-0606604OtherNMTS