Healthcare Provider Details

I. General information

NPI: 1720828916
Provider Name (Legal Business Name): BRANDON OBRYANT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

4048 RIVEROAKS RD
MILLBROOK AL
36054-4816
US

V. Phone/Fax

Practice location:
  • Phone: 786-390-3785
  • Fax:
Mailing address:
  • Phone: 786-390-3785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA28453
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: