Provider Demographics
NPI:1316567571
Name:POOLE, BRANDON M
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:M
Last Name:POOLE
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 1:3524 S VALLEY VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4685
Mailing Address - Country:US
Mailing Address - Phone:816-738-4063
Mailing Address - Fax:
Practice Address - Street 1:3545 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7310
Practice Address - Country:US
Practice Address - Phone:471-269-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180265942251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic