Healthcare Provider Details

I. General information

NPI: 1356694806
Provider Name (Legal Business Name): BRANNON PEDIATRIC SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 TOMMY AARON DR
GAINESVILLE GA
30506-1504
US

IV. Provider business mailing address

634 TOMMY AARON DR
GAINESVILLE GA
30506-1504
US

V. Phone/Fax

Practice location:
  • Phone: 770-503-7337
  • Fax:
Mailing address:
  • Phone: 770-503-7337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateGA

VIII. Authorized Official

Name: MRS. TAMMY C BRANNON
Title or Position: DIRECTOR/OWNER
Credential:
Phone: 770-503-7337