Healthcare Provider Details

I. General information

NPI: 1174458863
Provider Name (Legal Business Name): BRYCE DONOVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34101 FARENHOLT AVE BLDG 14
SAN DIEGO CA
92134-5291
US

IV. Provider business mailing address

949 FERN ST
ESCONDIDO CA
92027-1707
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-7968
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: