=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700144730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRANNON RESIDENTIAL ACHIEVEMENT GROUP, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2012
-----------------------------------------------------
Last Update Date | 04/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1376 E HURD RD
-----------------------------------------------------
City | CLIO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48420-7926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-670-0408
-----------------------------------------------------
Fax | 775-205-1651
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8345 JACLYN ANN DR
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48433-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-391-6008
-----------------------------------------------------
Fax | 775-205-1651
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LINDA K BRANNON
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 810-670-0408
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | AM250256548
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------