Healthcare Provider Details

I. General information

NPI: 1215842018
Provider Name (Legal Business Name): BRANDON LAWRENCE DASILVA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

642 ALL AMERICAN DRIVE
UNIVERSITY MS
38677
US

IV. Provider business mailing address

642 ALL AMERICAN DRIVE
UNIVERSITY MS
38677
US

V. Phone/Fax

Practice location:
  • Phone: 847-942-9909
  • Fax:
Mailing address:
  • Phone: 847-942-9909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: