Basic Information
| Provider Information | |||||||||
| NPI: | 1508440421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 775 POLE LINE RD W STE 307 | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088141000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 775 POLE LINE RD W STE 307 | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833015823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088141000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2021 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OTL-2379 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.