Provider Demographics
NPI:1801634464
Name:BRACEY, EDWARD DEMOND
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:DEMOND
Last Name:BRACEY
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 1:9923 WILSON BLVD
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-9022
Mailing Address - Country:US
Mailing Address - Phone:839-810-8443
Mailing Address - Fax:
Practice Address - Street 1:9923 WILSON BLVD
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-9022
Practice Address - Country:US
Practice Address - Phone:839-810-8443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0073603575172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver