Provider Demographics
NPI:1811535438
Name:ROUSE, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:ROUSE
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:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:BONDVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05340-0207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:503 WHITE PINE DRIVE
Practice Address - Street 2:
Practice Address - City:SOUTH LONDONDERRY
Practice Address - State:VT
Practice Address - Zip Code:05155
Practice Address - Country:US
Practice Address - Phone:802-770-8733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT91.0114227171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist