Provider Demographics
NPI:1720233034
Name:HACKETT, BRIAN KEITH
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:HACKETT
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 1:3425 ASHURST DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-5205
Mailing Address - Country:US
Mailing Address - Phone:229-834-1034
Mailing Address - Fax:866-493-9555
Practice Address - Street 1:3425 ASHURST DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-5205
Practice Address - Country:US
Practice Address - Phone:229-834-1034
Practice Address - Fax:866-493-9555
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment