Provider Demographics
NPI:1467845156
Name:BRADEN CLINIC LLC
Entity Type:Organization
Organization Name:BRADEN CLINIC LLC
Other - Org Name:BRADEN CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO, MPH MS
Authorized Official - Phone:239-867-4395
Mailing Address - Street 1:5050 AVE MARIA BLVD
Mailing Address - Street 2:
Mailing Address - City:AVE MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34142-9505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5050 AVE MARIA BLVD
Practice Address - Street 2:
Practice Address - City:AVE MARIA
Practice Address - State:FL
Practice Address - Zip Code:34142-9505
Practice Address - Country:US
Practice Address - Phone:239-867-4395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy