Provider Demographics
NPI:1508170952
Name:IMLER, BRIAN SCOTT (AT,C/L)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:SCOTT
Last Name:IMLER
Suffix:
Gender:M
Credentials:AT,C/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9539
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32006-0030
Mailing Address - Country:US
Mailing Address - Phone:904-982-5762
Mailing Address - Fax:904-529-6557
Practice Address - Street 1:3675 WINGED FOOT CIR
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-8023
Practice Address - Country:US
Practice Address - Phone:904-982-5762
Practice Address - Fax:904-529-6557
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL17142255A2300X
GAAT0010932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer