Healthcare Provider Details

I. General information

NPI: 1982176434
Provider Name (Legal Business Name): BRYAN S DORREL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 SPRING CANYON HTS APT 208
COLORADO SPRINGS CO
80907-3454
US

IV. Provider business mailing address

4515 SPRING CANYON HTS APT 208
COLORADO SPRINGS CO
80907-3454
US

V. Phone/Fax

Practice location:
  • Phone: 816-309-9238
  • Fax:
Mailing address:
  • Phone: 816-309-9238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0001948
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: