Provider Demographics
NPI:1174682066
Name:PACILLAS, BRYAN R (MPT)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:R
Last Name:PACILLAS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 N CHINOWTH ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4113
Mailing Address - Country:US
Mailing Address - Phone:559-671-0101
Mailing Address - Fax:559-590-4301
Practice Address - Street 1:1136 N CHINOWTH ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4113
Practice Address - Country:US
Practice Address - Phone:559-596-7101
Practice Address - Fax:559-671-0101
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT229092251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT229090OtherBLUE SHIELD
CAOPT229090OtherBLUE SHIELD
CAOPT229091Medicare PIN