| Doctor Name: | BRANDON VANVICKLE |
| NPI Number: | 1134522444 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 1109 Jones St Kennett, MO - 638573824 |
| Business Phone Number: | 5735594328 |
| Business Fax Number: | |
| Mailing Address: | 1109 Jones St, KENNETT |
| State: | MO |
| Postal Code: | 638573824 |
| Phone Number: | 5735594328 |
| Fax Number: | |
| NPI Enumeration Date: | 09/30/2014 |
| NPI Last Update Date: | 09/30/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 247200000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Technologists, Technicians & Other Technical Service Providers |
| Taxonomy Classification: | Technician, Other |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A collective term for persons with specialized training in various narrow fields of expertise whose occupations require training and skills in specific technical processes and procedures; and where further classification is deemed unnecessary by the user. |