Provider Demographics
NPI:1053853069
Name:PEPPER, BRANDON (PT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:PEPPER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 N GRANDVIEW AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-1621
Mailing Address - Country:US
Mailing Address - Phone:432-550-4700
Mailing Address - Fax:432-550-4715
Practice Address - Street 1:2525 N GRANDVIEW AVE STE 400
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-1621
Practice Address - Country:US
Practice Address - Phone:432-550-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1284006225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX365930201Medicaid
TX544325YLJGMedicare UPIN