Healthcare Provider Details

I. General information

NPI: 1528479573
Provider Name (Legal Business Name): MARY BUCHANAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 VICTORIA ST
BRANDON FL
33510-4100
US

IV. Provider business mailing address

701 VICTORIA STREET
BRANDON FL
33511
US

V. Phone/Fax

Practice location:
  • Phone: 813-691-4220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOTA0529
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: