Provider Demographics
NPI:1720692965
Name:ALLI, BRIAN ENVER
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ENVER
Last Name:ALLI
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 1:11278 BIG CANOE
Mailing Address - Street 2:
Mailing Address - City:BIG CANOE
Mailing Address - State:GA
Mailing Address - Zip Code:30143-5104
Mailing Address - Country:US
Mailing Address - Phone:404-449-6561
Mailing Address - Fax:
Practice Address - Street 1:27 LAUREL RIDGE LANE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-5104
Practice Address - Country:US
Practice Address - Phone:404-449-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT008084225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist