Individual
TARA BRACKLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
4000 MEDICAL CENTER DR, SUITE 207, FAYETTEVILLE, NY 13066-6631
(315) 637-1010
(315) 637-2010
Mailing address
6221 STATE ROUTE 31, SUITE 104, CICERO, NY 13039-8715
(315) 752-0141
(315) 752-0142
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
TUV008116
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
TUV008116
NYS LICENSE
NY
Enumeration date
06/11/2014
Last updated
06/11/2014
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