MEDICARE: BRANDON DEDERICH MPT, MS, 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
1	225100000X	Physical Therapist	26864	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	264440100	OTHER	CA	DEPT OF LABOR
2	OPT268640	OTHER	CA	BLUE SHIELD INDIVIDUAL
3	ZZZ082282	OTHER	CA	BLUE SHIELD GROUP#

General Provider Information

NPI Number	:	1912976853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON DEDERICH MPT, MS, ATC

Provider Business Mailing Address
First Line	:	144 W LOS ANGELES AVE STE 110
Second Line	:
City	:	MOORPARK
State	:	CA
Zip	:	93021-4218
Country	:	US
Telephone Number	:	805-552-1915
Fax Number	:	805-552-1991

Provider Business Practice Location Address
First Line	:	144 W LOS ANGELES AVE STE 110
Second Line	:
City	:	MOORPARK
State	:	CA
Zip	:	93021-4218
Country	:	US
Telephone Number	:	805-552-1915
Fax Number	:	805-552-1991

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	08/01/2022

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