MEDICARE: MR. BRIAN HOWARD LOCKE DPT, AT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer
2	225100000X	Physical Therapist	5501017207	MI

General Provider Information

NPI Number	:	1063480903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN HOWARD LOCKE DPT, AT, ATC

Provider Business Mailing Address
First Line	:	948 N ARROWHEAD RD
Second Line	:
City	:	WEIDMAN
State	:	MI
Zip	:	48893-9263
Country	:	US
Telephone Number	:	989-621-8673
Fax Number	:

Provider Business Practice Location Address
First Line	:	4851 E PICKARD ST STE 2600
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-2042
Country	:	US
Telephone Number	:	989-775-1657
Fax Number	:	989-775-1604

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	02/26/2018

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