Provider Demographics
NPI:1235701095
Name:FREIBERG, BRYAN D (LAC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:D
Last Name:FREIBERG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 SAN JUAN DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-3142
Mailing Address - Country:US
Mailing Address - Phone:808-754-5335
Mailing Address - Fax:
Practice Address - Street 1:2520 SAN JUAN DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-3142
Practice Address - Country:US
Practice Address - Phone:808-754-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-010086171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist