=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609081942
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON BRANTLEY P.T, A.T.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 HARRIS INDUSTRIAL BLVD
-----------------------------------------------------
City | VIDALIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30474-8845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-277-2044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 404
-----------------------------------------------------
City | ADRIAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31002-0404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 007647
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AT 001133
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------