Healthcare Provider Details

I. General information

NPI: 1881977312
Provider Name (Legal Business Name): BRANDE NICOLE SIMS IDMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 HARVEST FIELD WAY
FOUNTAIN CO
80817-3185
US

IV. Provider business mailing address

2400 S PACIFIC AVE BLDG 30
SAN PEDRO CA
90731-8103
US

V. Phone/Fax

Practice location:
  • Phone: 310-424-8040
  • Fax:
Mailing address:
  • Phone: 310-653-8568
  • Fax: 310-653-0888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: