Provider Demographics
NPI:1003566951
Name:MARET, BRANDON KENT (PTA)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:KENT
Last Name:MARET
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4656 1/2 GREENE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-1420
Mailing Address - Country:US
Mailing Address - Phone:908-377-6795
Mailing Address - Fax:
Practice Address - Street 1:800 LANTERN CREST WAY
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-4646
Practice Address - Country:US
Practice Address - Phone:619-258-8886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49605225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant