Provider Demographics
NPI:1790430742
Name:WATROUS, BRYAN WILLIAM (DACM, LAC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:WILLIAM
Last Name:WATROUS
Suffix:
Gender:M
Credentials:DACM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5620 CALLE VISTA ALEGRE
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-2465
Mailing Address - Country:US
Mailing Address - Phone:949-343-1622
Mailing Address - Fax:
Practice Address - Street 1:5620 CALLE VISTA ALEGRE
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92887-2465
Practice Address - Country:US
Practice Address - Phone:949-343-1622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19353171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist