MEDICARE: NICOLE M BRUECKNER

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1629772967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE M BRUECKNER

Provider Business Mailing Address
First Line	:	506 DAKOTA ST
Second Line	:
City	:	CARSON
State	:	ND
Zip	:	58529-4048
Country	:	US
Telephone Number	:	701-321-1358
Fax Number	:

Provider Business Practice Location Address
First Line	:	506 DAKOTA ST
Second Line	:
City	:	CARSON
State	:	ND
Zip	:	58529-4048
Country	:	US
Telephone Number	:	701-321-1358
Fax Number	:

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

Provider Enumeration Date	:	03/29/2023
Last Update Date	:	03/29/2023

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Directions to “ NICOLE M BRUECKNER ” Practice Location

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