Provider Demographics
NPI:1477183192
Name:DEMAINE, BRYAN GEORGE (ATC)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:GEORGE
Last Name:DEMAINE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3087 OLYMPUS DR NE
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-4411
Mailing Address - Country:US
Mailing Address - Phone:320-247-3330
Mailing Address - Fax:
Practice Address - Street 1:720 4TH AVE S # 133
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4498
Practice Address - Country:US
Practice Address - Phone:320-308-2588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer