MEDICARE: MS. TULLY ROBERT BRACKETT CAS I

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	174400000X	Specialist	3374	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3374	OTHER	CA	REGISTER CAS INTERN

General Provider Information

NPI Number	:	1730203753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TULLY ROBERT BRACKETT CAS I

Provider Business Mailing Address
First Line	:	295 ANDREWS ST
Second Line	:
City	:	AUBURN
State	:	CA
Zip	:	95603-4602
Country	:	US
Telephone Number	:	530-210-5719
Fax Number	:

Provider Business Practice Location Address
First Line	:	2914 COLD SPRINGS RD # B
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-4220
Country	:	US
Telephone Number	:	530-626-9240
Fax Number	:	530-626-8992

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

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	07/08/2007

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