MEDICARE: AMELIA LILLIAN BROADNAX

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1851672075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMELIA LILLIAN BROADNAX

Provider Business Mailing Address
First Line	:	PO BOX 1933
Second Line	:
City	:	LEMON GROVE
State	:	CA
Zip	:	91946-1933
Country	:	US
Telephone Number	:	858-609-9073
Fax Number	:

Provider Business Practice Location Address
First Line	:	4101 UNIVERSITY AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1418
Country	:	US
Telephone Number	:	858-609-9073
Fax Number	:

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

Provider Enumeration Date	:	09/01/2011
Last Update Date	:	03/15/2025

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