Provider Demographics
NPI:1801557442
Name:HAYTER, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:HAYTER
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 1:30816 COAST HWY
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-8136
Mailing Address - Country:US
Mailing Address - Phone:949-499-4190
Mailing Address - Fax:949-499-4698
Practice Address - Street 1:30816 COAST HWY
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-8136
Practice Address - Country:US
Practice Address - Phone:949-499-4190
Practice Address - Fax:949-499-4698
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21015174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty