Provider Demographics
NPI:1205173697
Name:BLAIR, BRANDON (NCTMB)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BLAIR
Suffix:
Gender:M
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3832 S BIG RIVER WAY
Mailing Address - Street 2:UNIT 2
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-7430
Mailing Address - Country:US
Mailing Address - Phone:801-633-9966
Mailing Address - Fax:
Practice Address - Street 1:455 E 400 S
Practice Address - Street 2:STE 20
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3008
Practice Address - Country:US
Practice Address - Phone:801-633-9966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5716461-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist