Healthcare Provider Details

I. General information

NPI: 1659533446
Provider Name (Legal Business Name): ALPHONSO BRYANT ORTHOTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 05/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 RILEY AVE STE. B
MACON GA
31204-0771
US

IV. Provider business mailing address

182 RILEY AVE STE. B
MACON GA
31204
US

V. Phone/Fax

Practice location:
  • Phone: 478-476-0201
  • Fax: 478-476-0202
Mailing address:
  • Phone: 478-476-0201
  • Fax: 478-476-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number73
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: