Provider Demographics
NPI:1124327812
Name:SMITH, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 AIRPORT BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-5930
Mailing Address - Country:US
Mailing Address - Phone:850-477-6966
Mailing Address - Fax:850-477-0267
Practice Address - Street 1:165 E INTENDENCIA ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-5805
Practice Address - Country:US
Practice Address - Phone:850-469-7555
Practice Address - Fax:850-469-7585
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26259225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist