Provider Demographics
NPI:1326475385
Name:LOVE, BRYAN WAYNE
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:WAYNE
Last Name:LOVE
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 1:5429 CARSO TER
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-6428
Mailing Address - Country:US
Mailing Address - Phone:941-429-6453
Mailing Address - Fax:
Practice Address - Street 1:9050 58TH DR E
Practice Address - Street 2:SUITE #101
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-6104
Practice Address - Country:US
Practice Address - Phone:941-807-5240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA30231225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist