MEDICARE: MR. BRANDON LAWRENCE ELLIOTT

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	3747A0650X	Attendant Care Provider	1111952	MN

General Provider Information

NPI Number	:	1326755778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRANDON LAWRENCE ELLIOTT

Provider Business Mailing Address
First Line	:	4141 5TH ST NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-2859
Country	:	US
Telephone Number	:	612-770-7045
Fax Number	:

Provider Business Practice Location Address
First Line	:	4141 5TH ST NE
Second Line	:
City	:	COLUMBIA HEIGHTS
State	:	MN
Zip	:	55421-2859
Country	:	US
Telephone Number	:	612-770-7045
Fax Number	:

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

Provider Enumeration Date	:	11/03/2022
Last Update Date	:	11/03/2022

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