Healthcare Provider Details

I. General information

NPI: 1083283675
Provider Name (Legal Business Name): BRANDON VIATOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 06/18/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PERSIMMON HOLLOW ROAD
STOLLINGS WV
25646-0274
US

IV. Provider business mailing address

PO BOX 274
STOLLINGS WV
25646-0274
US

V. Phone/Fax

Practice location:
  • Phone: 337-967-0493
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: