MEDICARE: MR. RANDALL SCOTT BRACKNEY ATC/LAT

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	2255A2300X	Athletic Trainer	36000387A	IN
2	2255A2300X	Athletic Trainer	AT 002171	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	36000387A	OTHER	IN	ATHLETIC TRAINERS LICENSE
2	AT 002171	OTHER	OH	ATHLETIC TRAINERS LICENSE

General Provider Information

NPI Number	:	1396709408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDALL SCOTT BRACKNEY ATC/LAT

Provider Business Mailing Address
First Line	:	302 LINCOLN ST
Second Line	:
City	:	PLAINFIELD
State	:	IN
Zip	:	46168-1158
Country	:	US
Telephone Number	:	317-839-3423
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 N PATTERSON BLVD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45402-1271
Country	:	US
Telephone Number	:	937-228-2287
Fax Number	:

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

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	07/08/2007

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