Provider Demographics
NPI:1891593190
Name:SABALA, BRANDON (IDC)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:SABALA
Suffix:
Gender:
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BEACHMASTER UNIT (BMU) 1 3205 ATTU ROAD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92155-0001
Mailing Address - Country:US
Mailing Address - Phone:916-837-9639
Mailing Address - Fax:
Practice Address - Street 1:BEACHMASTER UNIT (BMU) 1 3205 ATTU ROAD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-0001
Practice Address - Country:US
Practice Address - Phone:916-837-9639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty CorpsmanGroup - Single Specialty