1750315248 NPI number — MR. JERMAINE MONTREZ BRANTLEY RPT

Table of content: MR. JERMAINE MONTREZ BRANTLEY RPT (NPI 1750315248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750315248 NPI number — MR. JERMAINE MONTREZ BRANTLEY RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANTLEY
Provider First Name:
JERMAINE
Provider Middle Name:
MONTREZ
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750315248
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2841 BANYAN BOULEVARD CIR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431-6363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-988-5547
Provider Business Mailing Address Fax Number:
561-496-5201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13660 JOG RD
Provider Second Line Business Practice Location Address:
SUITE B3
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33446-3806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-496-5144
Provider Business Practice Location Address Fax Number:
561-496-5201
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 22634 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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