Provider Demographics
NPI:1396709408
Name:BRACKNEY, RANDALL SCOTT (ATC/LAT)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:SCOTT
Last Name:BRACKNEY
Suffix:
Gender:M
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-1158
Mailing Address - Country:US
Mailing Address - Phone:317-839-3423
Mailing Address - Fax:
Practice Address - Street 1:220 N PATTERSON BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-1271
Practice Address - Country:US
Practice Address - Phone:937-228-2287
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000387A2255A2300X
OHAT 0021712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN36000387AOtherATHLETIC TRAINERS LICENSE
OHAT 002171OtherATHLETIC TRAINERS LICENSE