Provider Demographics
NPI:1235229576
Name:BRACKENRICH FAMILY PRACTICE, PLC
Entity Type:Organization
Organization Name:BRACKENRICH FAMILY PRACTICE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-726-2375
Mailing Address - Street 1:363 WOODLAND STREET
Mailing Address - Street 2:PO BOX B
Mailing Address - City:RICH CREEK
Mailing Address - State:VA
Mailing Address - Zip Code:24147
Mailing Address - Country:US
Mailing Address - Phone:540-726-2375
Mailing Address - Fax:540-726-3573
Practice Address - Street 1:363 WOODLAND STREET
Practice Address - Street 2:
Practice Address - City:RICH CREEK
Practice Address - State:VA
Practice Address - Zip Code:24147
Practice Address - Country:US
Practice Address - Phone:540-726-2375
Practice Address - Fax:540-726-3573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0007995002Medicaid
VA49D0231961OtherCLIA NUMBER