Provider Demographics
NPI:1942507678
Name:WILLIAMS, BRYAN GLENN II
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:GLENN
Last Name:WILLIAMS
Suffix:II
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 1:208 SHEFFIELD ST
Mailing Address - Street 2:
Mailing Address - City:PHILIPSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16866-1848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 SHEFFIELD ST
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866-1848
Practice Address - Country:US
Practice Address - Phone:877-230-3885
Practice Address - Fax:402-505-9753
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE008905314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility