Provider Demographics
NPI:1669852240
Name:HUDDLESTON, BRYCE A
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:A
Last Name:HUDDLESTON
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 1:427 S MILL ST
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-7601
Mailing Address - Country:US
Mailing Address - Phone:417-753-7735
Mailing Address - Fax:417-753-7765
Practice Address - Street 1:16282 STATE HIGHWAY 13 STE F
Practice Address - Street 2:
Practice Address - City:BRANSON WEST
Practice Address - State:MO
Practice Address - Zip Code:65737-8875
Practice Address - Country:US
Practice Address - Phone:417-272-3909
Practice Address - Fax:417-272-3918
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015017509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist