Healthcare Provider Details

I. General information

NPI: 1003566951
Provider Name (Legal Business Name): BRANDON KENT MARET PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 LANTERN CREST WAY
SANTEE CA
92071-4646
US

IV. Provider business mailing address

4656 1/2 GREENE ST
SAN DIEGO CA
92107-1420
US

V. Phone/Fax

Practice location:
  • Phone: 619-258-8886
  • Fax:
Mailing address:
  • Phone: 908-377-6795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number49605
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: