Healthcare Provider Details

I. General information

NPI: 1306914437
Provider Name (Legal Business Name): MICHAEL BRACKE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12380 SW 82ND AVE
MIAMI FL
33156-5223
US

IV. Provider business mailing address

12380 SW 82ND AVE
MIAMI FL
33156-5223
US

V. Phone/Fax

Practice location:
  • Phone: 786-242-5710
  • Fax: 786-293-9103
Mailing address:
  • Phone: 786-242-5710
  • Fax: 786-293-9103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6601
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: