Provider Demographics
NPI:1083379614
Name:BRANDON, RICKY TRAVIS
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:TRAVIS
Last Name:BRANDON
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 1:2368 E 1035 S
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-3505
Mailing Address - Country:US
Mailing Address - Phone:801-836-4035
Mailing Address - Fax:
Practice Address - Street 1:2368 E 1035 S
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-3505
Practice Address - Country:US
Practice Address - Phone:801-836-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program