Healthcare Provider Details

I. General information

NPI: 1578409272
Provider Name (Legal Business Name): BRANDON ADAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2026
Last Update Date: 04/25/2026
Certification Date: 04/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S MAIN ST
ADA OH
45810-6000
US

IV. Provider business mailing address

6063 TYLER POINT DR
FAIRFIELD TOWNSHIP OH
45011-2177
US

V. Phone/Fax

Practice location:
  • Phone: 419-772-1051
  • Fax:
Mailing address:
  • Phone: 513-607-5529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number060004257
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: