Provider Demographics
NPI:1902319932
Name:BROMBERG, BRANDON (LMT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BROMBERG
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 GAYFER AVE APT 1314
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-3906
Mailing Address - Country:US
Mailing Address - Phone:251-895-4187
Mailing Address - Fax:
Practice Address - Street 1:901 GAYFER AVE APT 1314
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-3906
Practice Address - Country:US
Practice Address - Phone:251-895-4187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4890225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist