Provider Demographics
NPI:1235383621
Name:FREAY, BRYANT (LMT)
Entity Type:Individual
Prefix:MR
First Name:BRYANT
Middle Name:
Last Name:FREAY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16400 GOLF CLUB RD APT 111
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1668
Mailing Address - Country:US
Mailing Address - Phone:551-404-1584
Mailing Address - Fax:
Practice Address - Street 1:18642 NW 67TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-2406
Practice Address - Country:US
Practice Address - Phone:551-404-1584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA52208171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor