Provider Demographics
NPI:1073331344
Name:BRACK, PAIVI
Entity type:Individual
Prefix:MS
First Name:PAIVI
Middle Name:
Last Name:BRACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:BRACKA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1662
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83680
Mailing Address - Country:US
Mailing Address - Phone:208-315-6717
Mailing Address - Fax:208-315-6718
Practice Address - Street 1:1407 WEST MCMILLAN ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646
Practice Address - Country:US
Practice Address - Phone:208-315-6717
Practice Address - Fax:208-315-6718
Is Sole Proprietor?:No
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator