Healthcare Provider Details

I. General information

NPI: 1942785514
Provider Name (Legal Business Name): BRANDON NELSON ICBAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2018
Last Update Date: 09/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39210 STATE ST
FREMONT CA
94538-1456
US

IV. Provider business mailing address

31397 CAPE VIEW DR
UNION CITY CA
94587-5917
US

V. Phone/Fax

Practice location:
  • Phone: 510-399-7080
  • Fax:
Mailing address:
  • Phone: 510-909-8975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: