Healthcare Provider Details

I. General information

NPI: 1720036569
Provider Name (Legal Business Name): BRYAN EIDAL O. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 11TH ST
REEDLEY CA
93654-2902
US

IV. Provider business mailing address

1630 11TH ST
REEDLEY CA
93654-2902
US

V. Phone/Fax

Practice location:
  • Phone: 559-638-2246
  • Fax: 559-638-3777
Mailing address:
  • Phone: 559-638-2246
  • Fax: 559-638-3777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12890T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: