Provider Demographics
NPI:1477226629
Name:BROYLES, PANDORA (MT)
Entity Type:Individual
Prefix:MS
First Name:PANDORA
Middle Name:
Last Name:BROYLES
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:PANDY
Other - Middle Name:
Other - Last Name:BROYLES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MT
Mailing Address - Street 1:619 CRESTMONT DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2949
Mailing Address - Country:US
Mailing Address - Phone:937-254-2412
Mailing Address - Fax:
Practice Address - Street 1:7026 CORPORATE WAY STE 110
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4240
Practice Address - Country:US
Practice Address - Phone:937-609-4694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-25
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.004455225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist