MEDICARE: BRIAN FALLER PT, DPT, LAT, 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	PT38942	FL

General Provider Information

NPI Number	:	1467983189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN FALLER PT, DPT, LAT, ATC

Provider Business Mailing Address
First Line	:	4625 PORTOFINO WAY # 27-208
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33409-8148
Country	:	US
Telephone Number	:	516-281-6303
Fax Number	:

Provider Business Practice Location Address
First Line	:	5211 NORTH MILITARY TRAIL
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407
Country	:	US
Telephone Number	:	516-281-6303
Fax Number	:

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

Provider Enumeration Date	:	03/23/2017
Last Update Date	:	11/30/2023

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