Provider Demographics
NPI:1295785863
Name:BRASTOCK, CAROLE A (DC)
Entity type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:A
Last Name:BRASTOCK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:SHAUNA
Other - Middle Name:A
Other - Last Name:BRASTOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:300 S MADISON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-3124
Mailing Address - Country:US
Mailing Address - Phone:317-882-3280
Mailing Address - Fax:317-882-3281
Practice Address - Street 1:300 S MADISON AVE STE 103
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-3124
Practice Address - Country:US
Practice Address - Phone:317-882-3280
Practice Address - Fax:317-882-3281
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000991A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100226230BMedicaid
INU05694Medicare UPIN
IN100226230BMedicaid