Provider Demographics
NPI:1023502168
Name:ENVIVE BRANDON PROF LLC
Entity type:Organization
Organization Name:ENVIVE BRANDON PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LAVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-214-1401
Mailing Address - Street 1:220 E HOLLY BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:SD
Mailing Address - Zip Code:57005-1171
Mailing Address - Country:US
Mailing Address - Phone:605-582-3944
Mailing Address - Fax:
Practice Address - Street 1:220 E HOLLY BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:SD
Practice Address - Zip Code:57005-1171
Practice Address - Country:US
Practice Address - Phone:605-582-3944
Practice Address - Fax:605-582-3698
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENVIVE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-21
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty