Provider Demographics
NPI:1396107256
Name:MYERS, BRODY AUSTIN
Entity type:Individual
Prefix:
First Name:BRODY
Middle Name:AUSTIN
Last Name:MYERS
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 1:33718 SUNDROP AVE
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-4415
Mailing Address - Country:US
Mailing Address - Phone:760-443-5015
Mailing Address - Fax:
Practice Address - Street 1:33718 SUNDROP AVE
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-4415
Practice Address - Country:US
Practice Address - Phone:760-443-5015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer