MEDICARE: MR. CHARLES BRANHAM

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	:	1407183619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES BRANHAM

Provider Business Mailing Address
First Line	:	1195 FOREST BLUFF TRAIL
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78665
Country	:	US
Telephone Number	:	512-964-1747
Fax Number	:	800-960-6713

Provider Business Practice Location Address
First Line	:	1195 FOREST BLUFF TRL
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78665-3913
Country	:	US
Telephone Number	:	512-964-1747
Fax Number	:	800-960-6713

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

Provider Enumeration Date	:	11/09/2009
Last Update Date	:	11/09/2009

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Directions to “ MR. CHARLES BRANHAM ” Practice Location

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