MEDICARE: WHITNEY MARIE BRACK A.T.C., L.A.T

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	1321	AL

General Provider Information

NPI Number	:	1932477916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WHITNEY MARIE BRACK A.T.C., L.A.T

Provider Business Mailing Address
First Line	:	530 GARRETT OXLEY RD
Second Line	:
City	:	EASTMAN
State	:	GA
Zip	:	31023-2310
Country	:	US
Telephone Number	:	478-231-8103
Fax Number	:

Provider Business Practice Location Address
First Line	:	3230 STADIUM TOWERS
Second Line	:
City	:	TROY
State	:	AL
Zip	:	36082-0001
Country	:	US
Telephone Number	:	334-670-3720
Fax Number	:	334-670-3870

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

Provider Enumeration Date	:	12/06/2011
Last Update Date	:	12/06/2011

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