Provider Demographics
NPI:1720434822
Name:FANTASIA, BRANDON J (DC)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:J
Last Name:FANTASIA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N LEMON ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-3732
Mailing Address - Country:US
Mailing Address - Phone:909-984-2765
Mailing Address - Fax:909-467-5594
Practice Address - Street 1:410 N LEMON ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-3732
Practice Address - Country:US
Practice Address - Phone:909-984-2765
Practice Address - Fax:909-467-5594
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33564111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor