Provider Demographics
NPI:1780206946
Name:BUSH, RIAN C (LAC)
Entity Type:Individual
Prefix:
First Name:RIAN
Middle Name:C
Last Name:BUSH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:116 SAVANNAH AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4801
Mailing Address - Country:US
Mailing Address - Phone:912-243-9200
Mailing Address - Fax:912-243-9207
Practice Address - Street 1:116 SAVANNAH AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4801
Practice Address - Country:US
Practice Address - Phone:912-243-9200
Practice Address - Fax:912-243-9207
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA312262171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist