Provider Demographics
NPI:1790181188
Name:CHAMBLISS, BRYANT
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:CHAMBLISS
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 1:5343 DESOTO PKWY
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34234-3076
Mailing Address - Country:US
Mailing Address - Phone:941-586-8035
Mailing Address - Fax:
Practice Address - Street 1:5343 DESOTO PKWY
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34234-3076
Practice Address - Country:US
Practice Address - Phone:941-586-8035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3456171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist