Healthcare Provider Details

I. General information

NPI: 1003885427
Provider Name (Legal Business Name): RYAN STEPHEN HILDEBRAND IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 3005 S R 108
BRIDGEPORT CA
93517
US

IV. Provider business mailing address

BLDG 3005 SR 108 ATTN MEDICAL CLINIC
BRIDGEPORT CA
93517
US

V. Phone/Fax

Practice location:
  • Phone: 760-932-1614
  • Fax:
Mailing address:
  • Phone: 760-932-1614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: