Provider Demographics
NPI:1871529826
Name:BALLARD, BRIAN THOMAS (OFA)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:THOMAS
Last Name:BALLARD
Suffix:
Gender:M
Credentials:OFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 LUTHER FOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-4962
Mailing Address - Country:US
Mailing Address - Phone:850-509-0463
Mailing Address - Fax:
Practice Address - Street 1:760 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-2549
Practice Address - Country:US
Practice Address - Phone:850-997-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOFA 160225000000X
FLORF 168225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter