Healthcare Provider Details

I. General information

NPI: 1437625308
Provider Name (Legal Business Name): BRANDON WESLEY MCCAMMON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21150 BISCAYNE BLVD STE 406
AVENTURA FL
33180-1250
US

IV. Provider business mailing address

437 LIMERICK DR
LYNCHBURG OH
45142-9279
US

V. Phone/Fax

Practice location:
  • Phone: 305-935-9599
  • Fax:
Mailing address:
  • Phone: 937-728-1502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT41676
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: