Provider Demographics
NPI:1225718877
Name:BRYANT III, WILSON G
Entity Type:Individual
Prefix:MR
First Name:WILSON
Middle Name:G
Last Name:BRYANT III
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19196 PINE WAY
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-4914
Mailing Address - Country:US
Mailing Address - Phone:760-490-7367
Mailing Address - Fax:
Practice Address - Street 1:19196 PINE WAY
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308-4914
Practice Address - Country:US
Practice Address - Phone:760-490-7367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility