MEDICARE: GRACE BRACKE PT

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	225100000X	Physical Therapist	PT19618	FL

General Provider Information

NPI Number	:	1548338676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE BRACKE PT

Provider Business Mailing Address
First Line	:	12380 SW 82ND AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33156-5223
Country	:	US
Telephone Number	:	305-666-7538
Fax Number	:

Provider Business Practice Location Address
First Line	:	12380 SW 82ND AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33156-5223
Country	:	US
Telephone Number	:	305-666-7538
Fax Number	:

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

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	07/08/2007

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Directions to “ GRACE BRACKE PT” Practice Location

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