Basic Information
| Provider Information | |||||||||
| NPI: | 1720167752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLISS | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 307 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840110307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887006907 | ||||||||
| FaxNumber: | 8012946917 | ||||||||
| Practice Location | |||||||||
| Address1: | 3303 N UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846044438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013737438 | ||||||||
| FaxNumber: | 8013737486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 11/13/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3085245-2401 | UT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.