Provider Demographics
NPI:1689411340
Name:KELLUM, BRANDON JOHN (DISPENSING OPTICIAN)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JOHN
Last Name:KELLUM
Suffix:
Gender:M
Credentials:DISPENSING OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 MIRANDA CT
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-6658
Mailing Address - Country:US
Mailing Address - Phone:907-320-0663
Mailing Address - Fax:
Practice Address - Street 1:230 E MARYDALE AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7648
Practice Address - Country:US
Practice Address - Phone:907-262-3119
Practice Address - Fax:907-262-9290
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK202907156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician