Healthcare Provider Details

I. General information

NPI: 1104687847
Provider Name (Legal Business Name): BRANDON DECKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: BRANDON SIPE

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5444 RAVINE BLUFF CT
COLUMBUS OH
43231-3157
US

IV. Provider business mailing address

5444 RAVINE BLUFF CT
COLUMBUS OH
43231-3157
US

V. Phone/Fax

Practice location:
  • Phone: 419-701-9193
  • Fax:
Mailing address:
  • Phone: 419-701-9193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: