Provider Demographics
NPI:1407025547
Name:AMADOR, BRYAN K (BA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:K
Last Name:AMADOR
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1258
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46015-1258
Mailing Address - Country:US
Mailing Address - Phone:765-649-8161
Mailing Address - Fax:765-641-8350
Practice Address - Street 1:10731 N STATE ROAD 13
Practice Address - Street 2:
Practice Address - City:ELWOOD
Practice Address - State:IN
Practice Address - Zip Code:46036-8874
Practice Address - Country:US
Practice Address - Phone:765-552-5009
Practice Address - Fax:765-552-8347
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200898860Medicaid