Basic Information
| Provider Information | |||||||||
| NPI: | 1790332807 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIVAN | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | DPT, PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 E NORTH ST STE C | ||||||||
| Address2: | |||||||||
| City: | BRADLEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609151188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158027503 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17134 BEL RAY PL | ||||||||
| Address2: | |||||||||
| City: | BELTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640125331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163180434 | ||||||||
| FaxNumber: | 8163180437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2019 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070.024617 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2022039968 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.