=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114033552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRYANTS BLOOMERS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 PARK STREET
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-384-9937
-----------------------------------------------------
Fax | 904-389-1339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 PARK STREET
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-384-9937
-----------------------------------------------------
Fax | 904-389-1339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. CAROL S BRYANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-384-9937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------