1912990185 NPI number — KELLY ANN BRAUCHLA DC

Table of content: KELLY ANN BRAUCHLA DC (NPI 1912990185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912990185 NPI number — KELLY ANN BRAUCHLA DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAUCHLA
Provider First Name:
KELLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOGAN
Provider Other First Name:
KELLY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912990185
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
417 W 38TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDERSON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46013-4019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-642-7246
Provider Business Mailing Address Fax Number:
765-642-7246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
417 W 38TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDERSON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46013-4019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-642-7246
Provider Business Practice Location Address Fax Number:
765-642-7246
Provider Enumeration Date:
08/23/2005

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: 111N00000X , with the licence number:  08002193A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 227930A . This is a "MEDICARE ID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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