Provider Demographics
NPI:1053733972
Name:BOYD, BRANDON WALTER (LMP)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:WALTER
Last Name:BOYD
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GOETHALS DR
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4326
Mailing Address - Country:US
Mailing Address - Phone:509-947-4090
Mailing Address - Fax:
Practice Address - Street 1:731 GAGE BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-9701
Practice Address - Country:US
Practice Address - Phone:509-737-1461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-11
Last Update Date:2014-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60206550225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist