Provider Demographics
NPI:1467554964
Name:GRUBBS, BRYAN NATHANIEL (PT)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:NATHANIEL
Last Name:GRUBBS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 OLD WARREN ROAD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-3954
Mailing Address - Country:US
Mailing Address - Phone:870-367-1548
Mailing Address - Fax:870-367-1383
Practice Address - Street 1:1200 OLD WARREN ROAD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-3954
Practice Address - Country:US
Practice Address - Phone:870-367-1548
Practice Address - Fax:870-367-1383
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8152251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T112Medicare ID - Type Unspecified