MEDICARE: BRANDT LUKE

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
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1710584420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDT LUKE

Provider Business Mailing Address
First Line	:	6829 PLEASANT GATE LN
Second Line	:
City	:	COLLEGE GROVE
State	:	TN
Zip	:	37046-1435
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6829 PLEASANT GATE LN
Second Line	:
City	:	COLLEGE GROVE
State	:	TN
Zip	:	37046-1435
Country	:	US
Telephone Number	:	615-438-7104
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2020
Last Update Date	:	10/06/2020

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Directions to “ BRANDT LUKE ” Practice Location

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