Provider Demographics
NPI:1891970075
Name:TRUELUCK BROADNAX, BRENDA (MEDICAID PROVIDER)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:
Last Name:TRUELUCK BROADNAX
Suffix:
Gender:F
Credentials:MEDICAID PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 SW 27TH AVE
Mailing Address - Street 2:#2701
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-2042
Mailing Address - Country:US
Mailing Address - Phone:352-861-1590
Mailing Address - Fax:351-861-1590
Practice Address - Street 1:1421 SW 27TH AVE
Practice Address - Street 2:#2701
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-2042
Practice Address - Country:US
Practice Address - Phone:352-861-1590
Practice Address - Fax:351-861-1590
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor