Healthcare Provider Details

I. General information

NPI: 1336704816
Provider Name (Legal Business Name): BRANDON FISK CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 SAN ERNESTO AVE
ANCHORAGE AK
99508-2874
US

IV. Provider business mailing address

3805 CAROLINA DR # 2
ANCHORAGE AK
99517-2582
US

V. Phone/Fax

Practice location:
  • Phone: 907-887-6325
  • Fax:
Mailing address:
  • Phone: 907-887-6325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: