Healthcare Provider Details

I. General information

NPI: 1174135958
Provider Name (Legal Business Name): MR. BRYAN DE LA FUENTE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43520 DIVISION ST
LANCASTER CA
93535-4089
US

IV. Provider business mailing address

43520 DIVISION ST
LANCASTER CA
93535-4089
US

V. Phone/Fax

Practice location:
  • Phone: 661-266-4783
  • Fax: 661-266-1210
Mailing address:
  • Phone: 661-266-4783
  • Fax: 661-266-1210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: