Provider Demographics
NPI:1376255919
Name:BROADDUS EMPOWERMENT COMMUNITY SERVICES
Entity Type:Organization
Organization Name:BROADDUS EMPOWERMENT COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:WARDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MSWLMHPR
Authorized Official - Phone:804-217-4806
Mailing Address - Street 1:2101 E 142ND AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3629
Mailing Address - Country:US
Mailing Address - Phone:215-876-2802
Mailing Address - Fax:
Practice Address - Street 1:2101 E 142ND AVE APT 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3629
Practice Address - Country:US
Practice Address - Phone:215-876-2802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health