Provider Demographics
NPI:1376259663
Name:MCLEOD, BRANTFORD
Entity Type:Individual
Prefix:
First Name:BRANTFORD
Middle Name:
Last Name:MCLEOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 OLD BAINBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-3907
Mailing Address - Country:US
Mailing Address - Phone:850-694-7382
Mailing Address - Fax:
Practice Address - Street 1:2214 OLD BAINBRIDGE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-3907
Practice Address - Country:US
Practice Address - Phone:850-694-7382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM243-079-53-301-0172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver