Provider Demographics
NPI:1164715652
Name:RICHARDS, BRANDON K (PT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:K
Last Name:RICHARDS
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 1:904 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3932
Mailing Address - Country:US
Mailing Address - Phone:208-882-1426
Mailing Address - Fax:208-882-1428
Practice Address - Street 1:4765 S DURANGO DR
Practice Address - Street 2:106
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-8145
Practice Address - Country:US
Practice Address - Phone:702-898-7633
Practice Address - Fax:702-898-6433
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID7620225100000X
NV225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist