Provider Demographics
NPI:1346705456
Name:BRANDON, TERRENCE
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:
Last Name:BRANDON
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 1:3766 CHAPEL CV
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-2885
Mailing Address - Country:US
Mailing Address - Phone:770-892-8332
Mailing Address - Fax:470-401-1105
Practice Address - Street 1:415 TARPAN CT
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-4800
Practice Address - Country:US
Practice Address - Phone:770-892-8332
Practice Address - Fax:770-626-3262
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-02
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060-R-2073251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA060-R-2073Medicaid