Healthcare Provider Details

I. General information

NPI: 1912371188
Provider Name (Legal Business Name): BRANDON J PHELPS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2015
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 OCOTILLO DR STE B
EL CENTRO CA
92243
US

IV. Provider business mailing address

317 N EL CAMINO REAL STE 210
ENCINITAS CA
92024-2813
US

V. Phone/Fax

Practice location:
  • Phone: 760-679-0210
  • Fax: 760-679-0213
Mailing address:
  • Phone: 760-337-1144
  • Fax: 760-337-8259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number43358
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: