Healthcare Provider Details

I. General information

NPI: 1194645952
Provider Name (Legal Business Name): RANDY LYNN BRIANT JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 E BROADWAY
MAYFIELD KY
42066-2414
US

IV. Provider business mailing address

328 E BROADWAY
MAYFIELD KY
42066-2414
US

V. Phone/Fax

Practice location:
  • Phone: 270-970-3821
  • Fax:
Mailing address:
  • Phone: 270-970-3821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number1245803048
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: