Provider Demographics
NPI:1679671168
Name:CALDERON, BRIAN C (CMT, CST-D)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
Last Name:CALDERON
Suffix:
Gender:M
Credentials:CMT, CST-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3348
Mailing Address - Country:US
Mailing Address - Phone:218-829-4231
Mailing Address - Fax:218-829-4231
Practice Address - Street 1:224 N 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3348
Practice Address - Country:US
Practice Address - Phone:218-829-4231
Practice Address - Fax:218-829-4231
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN001091-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist