Healthcare Provider Details

I. General information

NPI: 1215571906
Provider Name (Legal Business Name): MR. BRANDON SHEA MIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10730 CHURCH ST APT 266
RANCHO CUCAMONGA CA
91730-6652
US

IV. Provider business mailing address

10730 CHURCH ST APT 266
RANCHO CUCAMONGA CA
91730-6652
US

V. Phone/Fax

Practice location:
  • Phone: 909-465-3151
  • Fax:
Mailing address:
  • Phone: 909-465-3151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: