Provider Demographics
NPI:1336855956
Name:BRANDON, RAY (LLC)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:BRANDON
Suffix:
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6558 W H AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-8557
Mailing Address - Country:US
Mailing Address - Phone:269-806-4601
Mailing Address - Fax:
Practice Address - Street 1:9731 HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083
Practice Address - Country:US
Practice Address - Phone:269-629-0324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022677251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health