Basic Information
| Provider Information | |||||||||
| NPI: | 1578162145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANSON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 389 SW SCALEHOUSE CT STE 130 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977023241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413064446 | ||||||||
| FaxNumber: | 5415502011 | ||||||||
| Practice Location | |||||||||
| Address1: | 389 SW SCALEHOUSE CT STE 130 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977023241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413064446 | ||||||||
| FaxNumber: | 5415502011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2020 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | 20-CRM-273 | OR | Y |
No ID Information.