Provider Demographics
NPI:1639360050
Name:CHILD, BRYAN F (DPT, ECS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:F
Last Name:CHILD
Suffix:
Gender:M
Credentials:DPT, ECS
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 12723
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84412-2723
Mailing Address - Country:US
Mailing Address - Phone:801-725-2380
Mailing Address - Fax:801-675-5103
Practice Address - Street 1:4700 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4303
Practice Address - Country:US
Practice Address - Phone:801-725-2380
Practice Address - Fax:801-675-5103
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT285241-24012251E1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000077404Medicare UPIN