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General NPI Number Information
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NPI Number | 1104240902
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Entity Type | Individual
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Provider Name | BRETT SPACK ATC, LAT
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Gender | Male
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Dates
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Enumeration Date | 02/13/2014
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Last Update Date | 02/13/2014
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Provider Practice Location Address
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Address Line | 1402 CHASE CT
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City | CARMEL
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State | IN
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Zip | 46032-7502
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Country | US
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Telephone | 317-848-5867
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Fax |
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Provider Business Mailing Address
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Address Line | 5131 CALLAN DR
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City | INDIANAPOLIS
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State | IN
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Zip | 46254-3774
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Country | US
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Telephone | 317-246-8715
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 36002164A
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License Number State | IN
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