Provider Demographics
NPI:1194014027
Name:HALL, BRENDON M (MS)
Entity Type:Individual
Prefix:
First Name:BRENDON
Middle Name:M
Last Name:HALL
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2670 S VOYAGER DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1294
Mailing Address - Country:US
Mailing Address - Phone:602-369-0823
Mailing Address - Fax:
Practice Address - Street 1:4111 E VALLEY AUTO DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4605
Practice Address - Country:US
Practice Address - Phone:602-369-0823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-13257225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist