Healthcare Provider Details

I. General information

NPI: 1639459332
Provider Name (Legal Business Name): BRANDON KEITH FLETCHER PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2011
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W BROADWAY BLVD STE 300
SEDALIA MO
65301-5708
US

IV. Provider business mailing address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

V. Phone/Fax

Practice location:
  • Phone: 660-827-2945
  • Fax: 660-827-2961
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-238-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2014031708
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2011030388
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: