Provider Demographics
NPI:1295271211
Name:CHURCH, BRANDON (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:CHURCH
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 S GREENE ST
Mailing Address - Street 2:
Mailing Address - City:ROCK RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:51246-2087
Mailing Address - Country:US
Mailing Address - Phone:507-210-8493
Mailing Address - Fax:
Practice Address - Street 1:1010 S GREENE ST
Practice Address - Street 2:
Practice Address - City:ROCK RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:51246-2087
Practice Address - Country:US
Practice Address - Phone:507-210-8493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-14
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30152255A2300X
SD06392255A2300X
2255A2300X
IA0971222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0639OtherSOUTH DAKOTA BOARD OF MEDICAL AND OSTEOPATHIC EXAMINERS
IA097122OtherIOWA DEPARTMENT OF PUBLIC HEALTH
MN3015OtherMINNESOTA BOARD OF MEDICAL PRACTICE