MEDICARE: MR. BRYANT FREAY LMT

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	171W00000X	Contractor	MA52208	FL

General Provider Information

NPI Number	:	1235383621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYANT FREAY LMT

Provider Business Mailing Address
First Line	:	16400 GOLF CLUB RD APT 111
Second Line	:
City	:	WESTON
State	:	FL
Zip	:	33326-1668
Country	:	US
Telephone Number	:	551-404-1584
Fax Number	:

Provider Business Practice Location Address
First Line	:	18642 NW 67TH AVE
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-2406
Country	:	US
Telephone Number	:	551-404-1584
Fax Number	:

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

Provider Enumeration Date	:	11/11/2008
Last Update Date	:	11/11/2008

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