Healthcare Provider Details

I. General information

NPI: 1417182353
Provider Name (Legal Business Name): MR. MIKE BRACE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 DABNEYS RD
RAPHINE VA
24472-2811
US

IV. Provider business mailing address

269 DABNEYS RD
RAPHINE VA
24472-2811
US

V. Phone/Fax

Practice location:
  • Phone: 540-377-5218
  • Fax:
Mailing address:
  • Phone: 540-377-5218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: