Provider Demographics
NPI:1306385521
Name:BALLINGER, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BALLINGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 EL MORADO ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-3010
Mailing Address - Country:US
Mailing Address - Phone:909-900-5311
Mailing Address - Fax:
Practice Address - Street 1:721 N VULCAN AVE
Practice Address - Street 2:STE 208
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2190
Practice Address - Country:US
Practice Address - Phone:760-634-1125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NCP20714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No251S00000XAgenciesCommunity/Behavioral Health