Provider Demographics
NPI:1487706438
Name:BRANDON INTEGRATED HEALTHCARE CLINICS INC
Entity type:Organization
Organization Name:BRANDON INTEGRATED HEALTHCARE CLINICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GENDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-685-5200
Mailing Address - Street 1:804 W BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7778
Mailing Address - Country:US
Mailing Address - Phone:813-685-5200
Mailing Address - Fax:813-654-8758
Practice Address - Street 1:804 W BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7778
Practice Address - Country:US
Practice Address - Phone:813-685-5200
Practice Address - Fax:813-654-8758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6328111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U13665Medicare UPIN
22710YMedicare ID - Type Unspecified