Provider Demographics
NPI:1194805689
Name:VANDIVER, BRIAN EUGENE (PT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:EUGENE
Last Name:VANDIVER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2129 UNITY CHURCH CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30558
Mailing Address - Country:US
Mailing Address - Phone:706-652-3907
Mailing Address - Fax:706-335-3819
Practice Address - Street 1:40095 US HIGHWAY 441
Practice Address - Street 2:ELITE PHYSICAL THERAPY
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529
Practice Address - Country:US
Practice Address - Phone:706-335-3816
Practice Address - Fax:706-335-3819
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00981439AMedicaid
GA00981439AMedicaid