Provider Demographics
NPI:1649577651
Name:RISS, BRYAN STEWART
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:STEWART
Last Name:RISS
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 1:438 COMMINS WAY
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755
Mailing Address - Country:US
Mailing Address - Phone:732-797-1771
Mailing Address - Fax:732-797-1818
Practice Address - Street 1:1907 NEW ROAD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08255
Practice Address - Country:US
Practice Address - Phone:732-797-1771
Practice Address - Fax:732-797-1818
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00689300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ38MC00689300OtherSTATE LICENSE