Provider Demographics
NPI:1770628125
Name:BURCH, BRYAN (PT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:BURCH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 HARTNELL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-1846
Mailing Address - Country:US
Mailing Address - Phone:530-226-9242
Mailing Address - Fax:530-226-9070
Practice Address - Street 1:320 HARTNELL AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1846
Practice Address - Country:US
Practice Address - Phone:530-226-9242
Practice Address - Fax:530-226-9070
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10998225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0109980Medicaid
CA0PT109980Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
CAZZZ23129ZMedicare ID - Type UnspecifiedMEDICARE GROUP