Basic Information
| Provider Information | |||||||||
| NPI: | 1912371188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 317 N EL CAMINO REAL STE 210 | ||||||||
| Address2: | |||||||||
| City: | ENCINITAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920242813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603371144 | ||||||||
| FaxNumber: | 7603378259 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 OCOTILLO DR STE B | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606790210 | ||||||||
| FaxNumber: | 7606790213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2015 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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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 | 43358 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.