MEDICARE: BRENNAN D LUNDGREN

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	225700000X	Massage Therapist	MA85903
2	225700000X	Massage Therapist	MA85903	FL

General Provider Information

NPI Number	:	1609540889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENNAN D LUNDGREN

Provider Business Mailing Address
First Line	:	5736 CHARLESTON ST
Second Line	:
City	:	DANIA BEACH
State	:	FL
Zip	:	33021
Country	:	US
Telephone Number	:	954-512-8284
Fax Number	:

Provider Business Practice Location Address
First Line	:	5736 CHARLESTON ST
Second Line	:
City	:	DANIA BEACH
State	:	FL
Zip	:	33021-3302
Country	:	US
Telephone Number	:	954-512-8284
Fax Number	:

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

Provider Enumeration Date	:	08/02/2021
Last Update Date	:	08/02/2021

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Directions to “ BRENNAN D LUNDGREN ” Practice Location

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