Provider Demographics
NPI:1104289966
Name:BRACK, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BRACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 FAIRWAY DR
Mailing Address - Street 2:APT. B
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5081
Mailing Address - Country:US
Mailing Address - Phone:575-993-9342
Mailing Address - Fax:
Practice Address - Street 1:2740 FAIRWAY DR
Practice Address - Street 2:APT. B
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5081
Practice Address - Country:US
Practice Address - Phone:575-993-9342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other