Healthcare Provider Details

I. General information

NPI: 1154527646
Provider Name (Legal Business Name): BRANDIE A COLLINS IDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 GRAPEVINE RD #205
VISTA CA
92083-4038
US

IV. Provider business mailing address

230 GRAPEVINE RD #205
VISTA CA
92083-4038
US

V. Phone/Fax

Practice location:
  • Phone: 901-874-3812
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: