MEDICARE: MR. BRANDON LEE BRADSHAW I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	80-0722004	TX

General Provider Information

NPI Number	:	1194094516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRANDON LEE BRADSHAW I

Provider Business Mailing Address
First Line	:	1431 CABLE RANCH RD APT 1811
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245-2138
Country	:	US
Telephone Number	:	210-473-5777
Fax Number	:

Provider Business Practice Location Address
First Line	:	1431 CABLE RANCH RD APT 1811
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78245-2138
Country	:	US
Telephone Number	:	210-473-5777
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2011
Last Update Date	:	12/14/2011

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