Provider Demographics
NPI:1881697035
Name:BRANDON MEDICAL WELLNESS CENTER
Entity type:Organization
Organization Name:BRANDON MEDICAL WELLNESS CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-684-8141
Mailing Address - Street 1:807 S PARSONS AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6063
Mailing Address - Country:US
Mailing Address - Phone:813-684-8141
Mailing Address - Fax:813-689-1140
Practice Address - Street 1:807 S PARSONS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6063
Practice Address - Country:US
Practice Address - Phone:813-684-8141
Practice Address - Fax:813-689-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0005360111N00000X
FLCH9344111N00000X
FLME46540207Q00000X
FLOT9814225X00000X
111N00000X
FLCH0005666111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6333650001Medicare NSC
FL98662Medicare ID - Type UnspecifiedGROUP
FLCJ8361Medicare PIN