Provider Demographics
NPI:1487808747
Name:BROOKS, TODD W
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:W
Last Name:BROOKS
Suffix:
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 1:1004 LONE JACK RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-5233
Mailing Address - Country:US
Mailing Address - Phone:434-455-9571
Mailing Address - Fax:434-528-4282
Practice Address - Street 1:1004 LONE JACK RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-5233
Practice Address - Country:US
Practice Address - Phone:434-455-9571
Practice Address - Fax:434-528-4282
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2705082490171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor