Healthcare Provider Details

I. General information

NPI: 1427025212
Provider Name (Legal Business Name): BRANSON NEPHROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 12/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SKAGGS RD SUITE 302
BRANSON MO
65616-2075
US

IV. Provider business mailing address

PO BOX 429
BRANSON MO
65615-0429
US

V. Phone/Fax

Practice location:
  • Phone: 417-334-8288
  • Fax: 417-334-6966
Mailing address:
  • Phone: 417-334-8288
  • Fax: 417-334-6966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN R MARTINEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 417-334-8288