Provider Demographics
NPI:1417381385
Name:UTT, BRYCE (LAC)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:UTT
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:PO BOX 988
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47202-0988
Mailing Address - Country:US
Mailing Address - Phone:812-374-4518
Mailing Address - Fax:800-774-0150
Practice Address - Street 1:2520 CALIFORNIA ST STE G
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-3677
Practice Address - Country:US
Practice Address - Phone:812-374-4518
Practice Address - Fax:800-774-0150
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN84000145A171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist