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General NPI Number Information
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NPI Number | 1487424354
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Entity Type | Individual
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Provider Name | BRANDON MAX WATERS
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Gender | Male
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Dates
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Enumeration Date | 01/03/2024
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Last Update Date | 01/03/2024
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Provider Practice Location Address
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Address Line | 10408 S 1055 W
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City | SOUTH JORDAN
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State | UT
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Zip | 84095-1510
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Country | US
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Telephone | 385-526-3385
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Fax |
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Provider Business Mailing Address
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Address Line | 4437 S 6000 W
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City | WEST VALLEY CITY
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State | UT
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Zip | 84128-5608
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Country | US
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Telephone | 385-219-6943
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 13712466-4701
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License Number State | UT
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