MEDICARE: DAMON DALE-EDWARD BRENSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor

General Provider Information

NPI Number	:	1063224038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAMON DALE-EDWARD BRENSON

Provider Business Mailing Address
First Line	:	235 BRONSON AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43608-1827
Country	:	US
Telephone Number	:	567-315-5269
Fax Number	:

Provider Business Practice Location Address
First Line	:	235 BRONSON AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43608-1827
Country	:	US
Telephone Number	:	567-315-5269
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2025
Last Update Date	:	01/24/2025

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Directions to “ DAMON DALE-EDWARD BRENSON ” Practice Location

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