Healthcare Provider Details

I. General information

NPI: 1114397312
Provider Name (Legal Business Name): BENJAMIN TYLER BRANDT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19629 NE 23RD ST
HARRAH OK
73045-9305
US

IV. Provider business mailing address

PO BOX 746
HARRAH OK
73045-0746
US

V. Phone/Fax

Practice location:
  • Phone: 405-454-0010
  • Fax: 405-454-0030
Mailing address:
  • Phone: 405-454-0010
  • Fax: 405-454-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2015
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5233
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: