Healthcare Provider Details

I. General information

NPI: 1275302127
Provider Name (Legal Business Name): BRANDON MICHAEL MIURA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12052 IMPERIAL HWY # 204
NORWALK CA
90650-3090
US

IV. Provider business mailing address

12873 PUEBLO LN
VICTORVILLE CA
92392-7931
US

V. Phone/Fax

Practice location:
  • Phone: 310-892-5812
  • Fax:
Mailing address:
  • Phone: 760-887-2605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number7452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: