Provider Demographics
NPI:1053385997
Name:BOYLS-WHITE, BRIAN GLEN (ATC)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:GLEN
Last Name:BOYLS-WHITE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 THE HEIGHTS LN
Mailing Address - Street 2:
Mailing Address - City:CALERA
Mailing Address - State:AL
Mailing Address - Zip Code:35040-7669
Mailing Address - Country:US
Mailing Address - Phone:703-690-4684
Mailing Address - Fax:
Practice Address - Street 1:1000 S STATE ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-2201
Practice Address - Country:US
Practice Address - Phone:734-763-9948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MIL9202442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer