Healthcare Provider Details

I. General information

NPI: 1255749891
Provider Name (Legal Business Name): BRANDON CLEAVES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8647 ROOK RD
INDIANAPOLIS IN
46234-1353
US

IV. Provider business mailing address

8647 ROOK RD
INDIANAPOLIS IN
46234-1353
US

V. Phone/Fax

Practice location:
  • Phone: 843-469-9782
  • Fax:
Mailing address:
  • Phone: 843-469-9782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: