Healthcare Provider Details

I. General information

NPI: 1629524574
Provider Name (Legal Business Name): BRANDON NOTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 SE OAK RIDGE DR. UNIT A
OAK GROVE MO
64075
US

IV. Provider business mailing address

509 SE OAK RIDGE DR APT A
OAK GROVE MO
64075-9290
US

V. Phone/Fax

Practice location:
  • Phone: 949-292-5514
  • Fax:
Mailing address:
  • Phone: 949-292-5513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2016023128
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: