Provider Demographics
NPI:1821815432
Name:UNDERWOOD, BRYAN (MS)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 PHILLIPS AVE
Mailing Address - Street 2:
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-1545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:264 PHILLIPS AVE
Practice Address - Street 2:
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-1545
Practice Address - Country:US
Practice Address - Phone:248-245-2559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist