Healthcare Provider Details

I. General information

NPI: 1447296694
Provider Name (Legal Business Name): BRYN JARALD HENDERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E CHAPMAN AVE
ORANGE CA
92866-1643
US

IV. Provider business mailing address

615 E CHAPMAN AVE
ORANGE CA
92866-1643
US

V. Phone/Fax

Practice location:
  • Phone: 714-639-4012
  • Fax: 714-639-4018
Mailing address:
  • Phone: 714-639-4012
  • Fax: 714-639-4018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A4401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: