MEDICARE: COREY BROADEN

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1225414584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY BROADEN

Provider Business Mailing Address
First Line	:	19796 SAN JUAN DR
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-1704
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19796 SAN JUAN DR
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-1704
Country	:	US
Telephone Number	:	313-450-3711
Fax Number	:

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

Provider Enumeration Date	:	08/09/2015
Last Update Date	:	08/09/2015

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Directions to “ COREY BROADEN ” Practice Location

Language	Start Address	Practice Location

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