Provider Demographics
NPI:1497304794
Name:BRYCE JOLLEY DPM INC
Entity Type:Organization
Organization Name:BRYCE JOLLEY DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYCE
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:760-771-8260
Mailing Address - Street 1:79405 HIGHWAY 111 STE 9-401
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-8300
Mailing Address - Country:US
Mailing Address - Phone:760-771-8260
Mailing Address - Fax:
Practice Address - Street 1:47647 CALEO BAY DR STE 110
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-8857
Practice Address - Country:US
Practice Address - Phone:760-771-8260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-09
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty