Provider Demographics
NPI:1194857474
Name:SEAGRAVES, BRIAN LAMONT
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:LAMONT
Last Name:SEAGRAVES
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 1:853 BLAZINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8228
Mailing Address - Country:US
Mailing Address - Phone:336-638-9400
Mailing Address - Fax:
Practice Address - Street 1:1705 YARBOROUGH DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-2747
Practice Address - Country:US
Practice Address - Phone:336-954-1577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC041808177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging