Provider Demographics
NPI:1881228401
Name:BRYANT, BO (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:BRYANT
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-9449
Mailing Address - Country:US
Mailing Address - Phone:817-598-2858
Mailing Address - Fax:
Practice Address - Street 1:2121 BETHEL RD
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76087-9449
Practice Address - Country:US
Practice Address - Phone:817-598-2858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer