Provider Demographics
NPI:1396478525
Name:DE LA SILVA, BRYAN KRISTOFFER
Entity type:Individual
Prefix:
First Name:BRYAN KRISTOFFER
Middle Name:
Last Name:DE LA SILVA
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 1:2025 CHAMPIONS DR APT 6C
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2587
Mailing Address - Country:US
Mailing Address - Phone:662-760-2179
Mailing Address - Fax:
Practice Address - Street 1:911 OLD HUMBOLDT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-5668
Practice Address - Country:US
Practice Address - Phone:731-256-5762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP19888225100000X
TN13655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist