Provider Demographics
NPI:1710508627
Name:BRYANT, MIKE ADAMS
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:ADAMS
Last Name:BRYANT
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 1:2910 S ARCHIBALD AVE # A421
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7323
Mailing Address - Country:US
Mailing Address - Phone:760-952-1786
Mailing Address - Fax:
Practice Address - Street 1:2910 S ARCHIBALD AVE STE A421
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7323
Practice Address - Country:US
Practice Address - Phone:760-952-1786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00858814376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide