Healthcare Provider Details

I. General information

NPI: 1194857474
Provider Name (Legal Business Name): MR. BRIAN LAMONT SEAGRAVES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 YARBOROUGH DR
GREENSBORO NC
27405-2747
US

IV. Provider business mailing address

853 BLAZINGWOOD DR
GREENSBORO NC
27406-8228
US

V. Phone/Fax

Practice location:
  • Phone: 336-954-1577
  • Fax:
Mailing address:
  • Phone: 336-638-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number041808
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: