Healthcare Provider Details

I. General information

NPI: 1285570911
Provider Name (Legal Business Name): DAESEAN BROADWATER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29706 EUCLID AVE
WICKLIFFE OH
44092-1831
US

IV. Provider business mailing address

29706 EUCLID AVE
WICKLIFFE OH
44092-1831
US

V. Phone/Fax

Practice location:
  • Phone: 330-840-8002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: