1467845156 NPI number — BRADEN CLINIC LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467845156 NPI number — BRADEN CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADEN CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BRADEN CLINIC PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467845156
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5050 AVE MARIA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AVE MARIA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34142-9505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 AVE MARIA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVE MARIA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34142-9505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-867-4395
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BRADEN
Authorized Official First Name:
BEAU
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
239-867-4395

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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