Healthcare Provider Details

I. General information

NPI: 1326503897
Provider Name (Legal Business Name): BRANDI LAWANE PUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 NORTHSIDE DR STE A150
MACON GA
31210-0450
US

IV. Provider business mailing address

102 FORMOSA WALK
MACON GA
31206-5221
US

V. Phone/Fax

Practice location:
  • Phone: 478-219-7568
  • Fax: 478-219-7321
Mailing address:
  • Phone: 478-731-9387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHRI011113
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: