Healthcare Provider Details

I. General information

NPI: 1336997998
Provider Name (Legal Business Name): BRIAN EAST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 LOLA AVE
ALTAVISTA VA
24517-1352
US

IV. Provider business mailing address

1317 LOLA AVE
ALTAVISTA VA
24517-1352
US

V. Phone/Fax

Practice location:
  • Phone: 434-369-6651
  • Fax:
Mailing address:
  • Phone: 434-369-6651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306601191
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: