Provider Demographics
NPI:1336350859
Name:R W BRACK P C
Entity Type:Organization
Organization Name:R W BRACK P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:256-574-5698
Mailing Address - Street 1:178 TAMMY GAINES LN
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35811-8951
Mailing Address - Country:US
Mailing Address - Phone:256-746-0170
Mailing Address - Fax:256-574-6939
Practice Address - Street 1:24833 JOHN T REID PKWY
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-2340
Practice Address - Country:US
Practice Address - Phone:256-574-5698
Practice Address - Fax:256-574-6939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS975TA537152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
J201Medicare ID - Type Unspecified