Healthcare Provider Details

I. General information

NPI: 1629241559
Provider Name (Legal Business Name): BRANDON CHARLES HOLDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43401 N. JEFFERSON BLDG #825
SELFRIDGE ANGB MI
48045
US

IV. Provider business mailing address

43401 N. JEFFERSON BLDG #825
SELFRIDGE ANGB MI
48045
US

V. Phone/Fax

Practice location:
  • Phone: 586-307-5017
  • Fax: 586-307-5010
Mailing address:
  • Phone: 586-307-5017
  • Fax: 586-307-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: