Healthcare Provider Details

I. General information

NPI: 1972414498
Provider Name (Legal Business Name): BRANDON BRETZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 S MADISON ST
LEBANON IL
62254-1743
US

IV. Provider business mailing address

96 MAGNOLIA DR APT 2215
GLEN CARBON IL
62034-1655
US

V. Phone/Fax

Practice location:
  • Phone: 618-310-3447
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160010267
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: