Healthcare Provider Details

I. General information

NPI: 1124844170
Provider Name (Legal Business Name): BRIAN SHOULDERS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 GEIST RD
FAIRBANKS AK
99709-3554
US

IV. Provider business mailing address

2001 BUTTERFIELD RD STE 1600
DOWNERS GROVE IL
60515-1211
US

V. Phone/Fax

Practice location:
  • Phone: 907-931-5223
  • Fax:
Mailing address:
  • Phone: 866-307-8206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501303618
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: