MEDICARE: MRS. STACI LYNN BRACKEN D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH8596	FL

General Provider Information

NPI Number	:	1346459021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACI LYNN BRACKEN D.C.

Provider Business Mailing Address
First Line	:	155 BLANDING BLVD STE 8
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-2624
Country	:	US
Telephone Number	:	904-213-9805
Fax Number	:	904-213-9806

Provider Business Practice Location Address
First Line	:	461 KINGSLEY AVE
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4827
Country	:	US
Telephone Number	:	904-213-9805
Fax Number	:	904-213-9806

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	03/03/2016

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