Provider Demographics
NPI:1760687883
Name:BRILEY, JOE GLEN (ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:JOE
Middle Name:GLEN
Last Name:BRILEY
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 HONEYSUCKLE LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-5728
Mailing Address - Country:US
Mailing Address - Phone:325-942-6163
Mailing Address - Fax:325-224-5911
Practice Address - Street 1:3501 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7610
Practice Address - Country:US
Practice Address - Phone:325-949-4357
Practice Address - Fax:325-224-9511
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT1879174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist