MEDICARE: MR. CHARLES DANA BRACK 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	1026	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00713739	OTHER	AZ	RAILROAD MEDICARE PTAN

General Provider Information

NPI Number	:	1982650693
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES DANA BRACK PT

Provider Business Mailing Address
First Line	:	4884 N LOUIS RIVER WAY
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85718-4755
Country	:	US
Telephone Number	:	520-797-7813
Fax Number	:

Provider Business Practice Location Address
First Line	:	4544 E CAMP LOWELL DR
Second Line	:	SUITE 150
City	:	TUCSON
State	:	AZ
Zip	:	85712-1282
Country	:	US
Telephone Number	:	520-884-0001
Fax Number	:	520-884-0199

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

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	07/23/2009

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Directions to “ MR. CHARLES DANA BRACK PT” Practice Location

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