Healthcare Provider Details

I. General information

NPI: 1396596417
Provider Name (Legal Business Name): BRANDON KENNETH LAWRENCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 04/01/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GRANDVIEW MEDICAL-DENTAL CLINIC (GMDC) 1000 WALLACE WAY
GRANDVIEW WA
98930
US

IV. Provider business mailing address

22436 BIRDS EYE DR
DIAMOND BAR CA
91765-2405
US

V. Phone/Fax

Practice location:
  • Phone: 509-788-1702
  • Fax: 509-786-1022
Mailing address:
  • Phone: 190-986-1048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14275122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: