Healthcare Provider Details

I. General information

NPI: 1063808350
Provider Name (Legal Business Name): BRANDON GEORGE MYERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MOTOR AVE
LOS ANGELES CA
90034-3740
US

IV. Provider business mailing address

3200 MOTOR AVE
LOS ANGELES CA
90034-3740
US

V. Phone/Fax

Practice location:
  • Phone: 310-836-1223
  • Fax:
Mailing address:
  • Phone: 310-836-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: