Healthcare Provider Details

I. General information

NPI: 1356544639
Provider Name (Legal Business Name): MR. BRYAN EDWARD HARRIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 BROADWAY ST
VALLEJO CA
94590-4519
US

IV. Provider business mailing address

228 BROADWAY ST
VALLEJO CA
94590-4519
US

V. Phone/Fax

Practice location:
  • Phone: 707-553-5331
  • Fax: 707-553-5653
Mailing address:
  • Phone: 707-553-5331
  • Fax: 707-553-5653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: