Provider Demographics
NPI:1699083329
Name:BROWN, BRANDON WILLIAM (LAC)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:WILLIAM
Last Name:BROWN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 SE 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1506
Mailing Address - Country:US
Mailing Address - Phone:503-902-1099
Mailing Address - Fax:
Practice Address - Street 1:1988 SE LADD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4737
Practice Address - Country:US
Practice Address - Phone:503-902-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC152714171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist