Healthcare Provider Details

I. General information

NPI: 1013488196
Provider Name (Legal Business Name): BROOKE NACK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 FRANCISCAN WAY STE 400
MICHIGAN CITY IN
46360
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-878-8200
  • Fax: 219-878-8331
Mailing address:
  • Phone: 317-528-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05007756A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: