Healthcare Provider Details

I. General information

NPI: 1871901157
Provider Name (Legal Business Name): BRADEN CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5068 ANNUNCIATION CIR UNIT 111
AVE MARIA FL
34142-9668
US

IV. Provider business mailing address

5068 ANNUNCIATION CIR UNIT 111
AVE MARIA FL
34142-9668
US

V. Phone/Fax

Practice location:
  • Phone: 239-867-4395
  • Fax: 239-217-3662
Mailing address:
  • Phone: 239-867-4395
  • Fax: 239-217-3662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS12519
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME104654
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License NumberOS12519
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberOS12519
License Number StateFL
# 10
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS13007
License Number StateFL
# 11
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberOS13007
License Number StateFL
# 12
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS12519
License Number StateFL

VIII. Authorized Official

Name: ANA MARIA GARCIA IGUARAN
Title or Position: SOLE OWNER
Credential: MD
Phone: 405-317-1258