Provider Demographics
NPI:1508460825
Name:LOVE-EL, BRIAN ODELL
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ODELL
Last Name:LOVE-EL
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 1:260 NORTHERN AVE APT 2I
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-1758
Mailing Address - Country:US
Mailing Address - Phone:478-444-1043
Mailing Address - Fax:
Practice Address - Street 1:260 NORTHERN AVE APT 2I
Practice Address - Street 2:
Practice Address - City:AVONDALE ESTATES
Practice Address - State:GA
Practice Address - Zip Code:30002-1758
Practice Address - Country:US
Practice Address - Phone:478-444-1043
Practice Address - Fax:478-444-1043
Is Sole Proprietor?:No
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009568225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist