Healthcare Provider Details

I. General information

NPI: 1124327812
Provider Name (Legal Business Name): BRIAN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1464 TIGER PARK LN # A-2
GULF BREEZE FL
32563-5718
US

IV. Provider business mailing address

2065 AIRPORT BLVD STE 300
PENSACOLA FL
32504-5930
US

V. Phone/Fax

Practice location:
  • Phone: 850-934-1833
  • Fax: 850-934-1641
Mailing address:
  • Phone: 850-477-6966
  • Fax: 850-477-0267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT26259
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: