Provider Demographics
NPI:1558758664
Name:DAIGNEAULT, BRIAN MICHAEL (ATC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:DAIGNEAULT
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 1:229 HOPE ST BOX 1933
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02912-0001
Mailing Address - Country:US
Mailing Address - Phone:401-863-3851
Mailing Address - Fax:401-863-1156
Practice Address - Street 1:229 HOPE ST BOX 1933
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02912-0001
Practice Address - Country:US
Practice Address - Phone:401-863-3851
Practice Address - Fax:401-863-1156
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAT000912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer