Provider Demographics
NPI:1699316315
Name:CACCIOLA, BRENDAN
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:CACCIOLA
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 1:484 JOSIAH BARTLETT RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-5928
Mailing Address - Country:US
Mailing Address - Phone:603-545-2028
Mailing Address - Fax:
Practice Address - Street 1:484 JOSIAH BARTLETT RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-5928
Practice Address - Country:US
Practice Address - Phone:603-545-2028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program