Provider Demographics
NPI:1760903447
Name:DIEKMANN, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:DIEKMANN
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:PO BOX 2743
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-2743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1140 EDWARDS VILLAGE BLVD. STE 105
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-569-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer