Provider Demographics
NPI:1497232680
Name:CARTER, BRANDON CLARK
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:CLARK
Last Name:CARTER
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 1:311 PENDLETON LN
Mailing Address - Street 2:
Mailing Address - City:STRASBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22657-2187
Mailing Address - Country:US
Mailing Address - Phone:304-995-8074
Mailing Address - Fax:
Practice Address - Street 1:27 BRENTWOOD ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25404-7531
Practice Address - Country:US
Practice Address - Phone:304-995-8074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV150122417133NN1002X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education