Provider Demographics
NPI:1912136300
Name:BRAYBOY, DARRELL DAVID (LAC)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:DAVID
Last Name:BRAYBOY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1162 TERRACE CT
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-1241
Mailing Address - Country:US
Mailing Address - Phone:847-242-0927
Mailing Address - Fax:847-242-0928
Practice Address - Street 1:1162 TERRACE CT
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:IL
Practice Address - Zip Code:60022-1241
Practice Address - Country:US
Practice Address - Phone:847-242-0927
Practice Address - Fax:847-242-0928
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000465171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist