Basic Information
Provider Information | |||||||||
NPI: | 1528114378 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GENTRY | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | CLAY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 151 FM 610 | ||||||||
Address2: |   | ||||||||
City: | ASPERMONT | ||||||||
State: | TX | ||||||||
PostalCode: | 795022302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9409884216 | ||||||||
FaxNumber: | 9409884217 | ||||||||
Practice Location | |||||||||
Address1: | 347 NORTH MAIN ST. | ||||||||
Address2: |   | ||||||||
City: | JAYTON | ||||||||
State: | TX | ||||||||
PostalCode: | 79528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8062372145 | ||||||||
FaxNumber: | 8062372147 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/26/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1135713 | TX | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.