Provider Demographics
NPI:1528138732
Name:BRINK, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BRINK
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:PO BOX 1790
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-1790
Mailing Address - Country:US
Mailing Address - Phone:307-358-9464
Mailing Address - Fax:307-358-9330
Practice Address - Street 1:453 VANDEHEI AVE
Practice Address - Street 2:SUITES 130, 140
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-6010
Practice Address - Country:US
Practice Address - Phone:307-514-5834
Practice Address - Fax:307-514-5837
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA106348Medicare PIN