Provider Demographics
NPI:1457684219
Name:REID, BRYAN W (DC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:W
Last Name:REID
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2136 VADALABENE DR STE B
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5828
Mailing Address - Country:US
Mailing Address - Phone:618-205-3240
Mailing Address - Fax:618-205-3598
Practice Address - Street 1:2136 VADALABENE DR STE B
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5828
Practice Address - Country:US
Practice Address - Phone:618-205-3240
Practice Address - Fax:618-205-3598
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2023-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000157548111N00000X
IL038.010417111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor