Healthcare Provider Details

I. General information

NPI: 1407171390
Provider Name (Legal Business Name): BRYCE D JOLLEY DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2010
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47647 CALEO BAY DR STE 110
LA QUINTA CA
92253-8857
US

IV. Provider business mailing address

79405 HIGHWAY 111
LA QUINTA CA
92253-8300
US

V. Phone/Fax

Practice location:
  • Phone: 760-771-8260
  • Fax: 760-564-1418
Mailing address:
  • Phone: 760-711-8260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5582
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000875
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: