Provider Demographics
NPI:1114664083
Name:BRYANT, GEORGE LEROY IV
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:LEROY
Last Name:BRYANT
Suffix:IV
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 1:7801 TOWCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-7780
Mailing Address - Country:US
Mailing Address - Phone:804-898-5604
Mailing Address - Fax:
Practice Address - Street 1:6800 LUCY CORR CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6657
Practice Address - Country:US
Practice Address - Phone:804-748-1511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605325225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty