=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669549861
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAKE CHIROPRACTIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4010 E NORTH ST STE 1
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-6208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-292-2503
-----------------------------------------------------
Fax | 864-292-2504
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4010 E NORTH ST STE 1
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-6208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-292-2503
-----------------------------------------------------
Fax | 864-292-2504
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BARBARA LYNN BRAKE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 864-292-2503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0965
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------