Provider Demographics
NPI:1225559982
Name:AVERY, BRANDON SCOTT
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:SCOTT
Last Name:AVERY
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 1:19801 TOMAHAWK RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-5013
Mailing Address - Country:US
Mailing Address - Phone:760-628-9195
Mailing Address - Fax:760-628-9195
Practice Address - Street 1:19801 TOMAHAWK RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-5013
Practice Address - Country:US
Practice Address - Phone:760-628-9195
Practice Address - Fax:760-628-9195
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA336427614374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA336427614OtherLICENSED FACILITY NUMBER