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NPI Code Detail

MEDICARE: BRANDON CHURCH MS, LAT, ATC

MEDICARE: BRANDON CHURCH MS, LAT, ATC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer3015MN
22255A2300XAthletic Trainer0639SD
32255A2300XAthletic Trainer
42255A2300XAthletic Trainer097122IA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
10639OTHERSDSOUTH DAKOTA BOARD OF MEDICAL AND OSTEOPATHIC EXAMINERS
2097122OTHERIAIOWA DEPARTMENT OF PUBLIC HEALTH
33015OTHERMNMINNESOTA BOARD OF MEDICAL PRACTICE

General Provider Information

NPI Number : 1295271211
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRANDON CHURCH MS, LAT, ATC
Provider Business Mailing Address
First Line : 1010 S GREENE ST
Second Line :
City : ROCK RAPIDS
State : IA
Zip : 51246-2087
Country : US
Telephone Number : 507-210-8493
Fax Number :
Provider Business Practice Location Address
First Line : 1010 S GREENE ST
Second Line :
City : ROCK RAPIDS
State : IA
Zip : 51246-2087
Country : US
Telephone Number : 507-210-8493
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/14/2017
Last Update Date : 07/27/2020

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Directions to “ BRANDON CHURCH MS, LAT, ATC” Practice Location

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