Provider Demographics
NPI:1518593110
Name:PRIDE, BERTRAM
Entity Type:Individual
Prefix:
First Name:BERTRAM
Middle Name:
Last Name:PRIDE
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 1:8931 PARDEE RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-2741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1640 REDSTONE CENTER DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7605
Practice Address - Country:US
Practice Address - Phone:214-264-9711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703111838164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse