Healthcare Provider Details

I. General information

NPI: 1629020128
Provider Name (Legal Business Name): MR. BRANDON BARKSDALE
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 W 108TH ST
CHICAGO IL
60628-3452
US

IV. Provider business mailing address

129 W 108TH ST
CHICAGO IL
60628-3452
US

V. Phone/Fax

Practice location:
  • Phone: 773-568-0884
  • Fax:
Mailing address:
  • Phone: 773-568-0884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: