Healthcare Provider Details

I. General information

NPI: 1407878689
Provider Name (Legal Business Name): BRYAN J LIND PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15884 MANCHESTER RD
ELLISVILLE MO
63011-2208
US

IV. Provider business mailing address

13537 BARRETT PARKWAY DR SUITE 105
BALLWIN MO
63021-5899
US

V. Phone/Fax

Practice location:
  • Phone: 636-391-5400
  • Fax: 636-394-9674
Mailing address:
  • Phone: 314-821-9126
  • Fax: 314-821-9142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2004020795
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: