Provider Demographics
NPI:1457147043
Name:OLIVE, BRYCKEN GWYN
Entity type:Individual
Prefix:
First Name:BRYCKEN
Middle Name:GWYN
Last Name:OLIVE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2708 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-4830
Mailing Address - Country:US
Mailing Address - Phone:808-280-2804
Mailing Address - Fax:
Practice Address - Street 1:301 N LAKE AVE STE 600
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-5129
Practice Address - Country:US
Practice Address - Phone:626-354-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program