Provider Demographics
NPI:1114902392
Name:BRANHAM, FD BLADE (PT)
Entity Type:Individual
Prefix:
First Name:FD BLADE
Middle Name:
Last Name:BRANHAM
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 1:5962 LA PLACE COURT
Mailing Address - Street 2:SUITE 170
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008
Mailing Address - Country:US
Mailing Address - Phone:800-929-4776
Mailing Address - Fax:760-931-8370
Practice Address - Street 1:73345 HIGHWAY 111 STE 103
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260
Practice Address - Country:US
Practice Address - Phone:760-340-1812
Practice Address - Fax:760-340-1852
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15311225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT153111Medicare ID - Type Unspecified