Provider Demographics
NPI:1063991354
Name:ANTONISSEN, BRANDON (DC)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:ANTONISSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1968 S COAST HWY
Mailing Address - Street 2:STE 1073
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3681
Mailing Address - Country:US
Mailing Address - Phone:949-228-1147
Mailing Address - Fax:
Practice Address - Street 1:5 JOURNEY STE 100
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-5330
Practice Address - Country:US
Practice Address - Phone:949-228-1147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34287111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor