MEDICARE: BREANNA RENEE MARSHALL O.D.

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	152W00000X	Optometrist	4901004724	MI

General Provider Information

NPI Number	:	1861757627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANNA RENEE MARSHALL O.D.

Provider Business Mailing Address
First Line	:	1379 FLUSHING RD
Second Line	:
City	:	FLUSHING
State	:	MI
Zip	:	48433-2262
Country	:	US
Telephone Number	:	810-659-3135
Fax Number	:	810-659-0024

Provider Business Practice Location Address
First Line	:	1379 FLUSHING RD
Second Line	:
City	:	FLUSHING
State	:	MI
Zip	:	48433-2262
Country	:	US
Telephone Number	:	810-659-3135
Fax Number	:	810-659-0024

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

Provider Enumeration Date	:	07/09/2012
Last Update Date	:	10/22/2020

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