1164728309 NPI number — MR. EDWARD V. BRACKENBURY MFT

Table of content: MR. EDWARD V. BRACKENBURY MFT (NPI 1164728309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164728309 NPI number — MR. EDWARD V. BRACKENBURY MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRACKENBURY
Provider First Name:
EDWARD
Provider Middle Name:
V.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164728309
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
807 E GREENWICH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALO ALTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94303-3417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-324-0619
Provider Business Mailing Address Fax Number:
650-327-9521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 UNIVERSITY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENLO PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94025-4262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
659-324-0619
Provider Business Practice Location Address Fax Number:
650-327-9521
Provider Enumeration Date:
02/06/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC 7563 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MFC 7563 . This is a "MFT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".