MEDICARE: DAREL MARTIN BRAZELTON SR.

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	343800000X	Secured Medical Transport (VAN)

General Provider Information

NPI Number	:	1770395717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAREL MARTIN BRAZELTON SR.

Provider Business Mailing Address
First Line	:	4040 BROADWAY STE 240
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-6300
Country	:	US
Telephone Number	:	480-262-2912
Fax Number	:

Provider Business Practice Location Address
First Line	:	4040 BROADWAY STE 240
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209-6300
Country	:	US
Telephone Number	:	480-262-2912
Fax Number	:

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

Provider Enumeration Date	:	01/27/2025
Last Update Date	:	02/06/2025

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