Healthcare Provider Details

I. General information

NPI: 1336426519
Provider Name (Legal Business Name): CASEY BRAUCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14902 S ROUTE 59
PLAINFIELD IL
60544-2728
US

IV. Provider business mailing address

14902 S ROUTE 59
PLAINFIELD IL
60544-2728
US

V. Phone/Fax

Practice location:
  • Phone: 815-254-5792
  • Fax: 815-254-6847
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.291912
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: