Provider Demographics
NPI:1134557945
Name:SPAIN, BRYAN KEITH (DPT)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:KEITH
Last Name:SPAIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 W 2ND ST N
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-2562
Mailing Address - Country:US
Mailing Address - Phone:804-339-7066
Mailing Address - Fax:
Practice Address - Street 1:204 W 2ND ST N
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-2562
Practice Address - Country:US
Practice Address - Phone:804-339-7066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-15
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206750225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist