Provider Demographics
NPI:1245768928
Name:CARLUCCI, BRANDON TYLER
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:TYLER
Last Name:CARLUCCI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8A PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NH
Mailing Address - Zip Code:03275-1434
Mailing Address - Country:US
Mailing Address - Phone:603-340-0580
Mailing Address - Fax:
Practice Address - Street 1:105 E MADISON ST
Practice Address - Street 2:
Practice Address - City:WINTERSET
Practice Address - State:IA
Practice Address - Zip Code:50273-2412
Practice Address - Country:US
Practice Address - Phone:603-340-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087661111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor