Basic Information
| Provider Information | |||||||||
| NPI: | 1982650693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRACK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | DANA | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4884 N LOUIS RIVER WAY | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857184755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207977813 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4544 E CAMP LOWELL DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857121282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208840001 | ||||||||
| FaxNumber: | 5208840199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 07/23/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1026 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00713739 | 01 | AZ | RAILROAD MEDICARE PTAN | OTHER |