Provider Demographics
NPI:1730635376
Name:REYES, BRIAN ALEXANDER (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ALEXANDER
Last Name:REYES
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 1:1904 BAY PINE CIR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-9423
Mailing Address - Country:US
Mailing Address - Phone:954-629-3517
Mailing Address - Fax:
Practice Address - Street 1:100 SERVAIS WAY
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544
Practice Address - Country:US
Practice Address - Phone:850-884-4661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0015542255A2300X
FLAL62662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer