1750833828 NPI number — BRAYDEN STARR PT, DPT, ATC

Table of content: BRAYDEN STARR PT, DPT, ATC (NPI 1750833828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750833828 NPI number — BRAYDEN STARR PT, DPT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STARR
Provider First Name:
BRAYDEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, ATC
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:
1750833828
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1365 N BELSAY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48509-1602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-250-6112
Provider Business Mailing Address Fax Number:
810-250-6113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1365 N BELSAY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48509-1602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
102-506-1128
Provider Business Practice Location Address Fax Number:
810-250-6113
Provider Enumeration Date:
10/25/2016

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: 2255A2300X , with the licence number:  2601001794 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 5501019871 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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