Provider Demographics
NPI:1477512564
Name:RAYPOLE, BRIAN THOMAS (LAT ATC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:THOMAS
Last Name:RAYPOLE
Suffix:
Gender:M
Credentials:LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 BLUEGRASS LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6455
Mailing Address - Country:US
Mailing Address - Phone:260-485-2985
Mailing Address - Fax:
Practice Address - Street 1:5050 N. CLINTON STREET
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809
Practice Address - Country:US
Practice Address - Phone:260-484-8551
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001169A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer