MEDICARE: BRANDON LEE TORNAVACCA

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	111N00000X	Chiropractor	CH14758	FL

General Provider Information

NPI Number	:	1619759164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON LEE TORNAVACCA

Provider Business Mailing Address
First Line	:	3821 WOODBRIAR TRL STE 3
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-9611
Country	:	US
Telephone Number	:	352-205-2049
Fax Number	:

Provider Business Practice Location Address
First Line	:	3821 WOODBRIAR TRL
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-9611
Country	:	US
Telephone Number	:	386-265-1579
Fax Number	:

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

Provider Enumeration Date	:	10/19/2023
Last Update Date	:	10/19/2023

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