Provider Demographics
NPI:1194332379
Name:BAINES, BRYAN KEITH SR (LAT, ATC, EMT)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:KEITH
Last Name:BAINES
Suffix:SR
Gender:M
Credentials:LAT, ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4266 ANGELINE DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-5002
Mailing Address - Country:US
Mailing Address - Phone:248-765-2487
Mailing Address - Fax:
Practice Address - Street 1:4333 JOHN R RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-3681
Practice Address - Country:US
Practice Address - Phone:248-823-2981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer