Provider Demographics
NPI:1356628614
Name:BRILES, KEVIN WILLIAM SR (AT,C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:BRILES
Suffix:SR
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 FRIES MILL RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLINVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08322-2503
Mailing Address - Country:US
Mailing Address - Phone:856-694-0100
Mailing Address - Fax:856-694-4615
Practice Address - Street 1:242 FRIES MILL RD
Practice Address - Street 2:
Practice Address - City:FRANKLINVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08322-2503
Practice Address - Country:US
Practice Address - Phone:856-694-0100
Practice Address - Fax:856-694-4615
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT000867002255A2300X
PART0049952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer