Healthcare Provider Details

I. General information

NPI: 1366884686
Provider Name (Legal Business Name): BRYAN JACOB WILLBANKS IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2013
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3155 SALMON ST
SAN DIEGO CA
92124-3641
US

IV. Provider business mailing address

3155 SALMON ST
SAN DIEGO CA
92124-3641
US

V. Phone/Fax

Practice location:
  • Phone: 843-475-5341
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: