Provider Demographics
NPI:1073238465
Name:BRYANT, JIMMY JR
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:BRYANT
Suffix:JR
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 E TWELVE OAKS RD
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-9601
Mailing Address - Country:US
Mailing Address - Phone:407-978-9992
Mailing Address - Fax:
Practice Address - Street 1:174 E TWELVE OAKS RD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-9601
Practice Address - Country:US
Practice Address - Phone:407-978-9992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)