Healthcare Provider Details

I. General information

NPI: 1164044236
Provider Name (Legal Business Name): BRYANT HEALTHY LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19404 N. CREEK DRIVE
LYNWOOD IL
60411
US

IV. Provider business mailing address

19404 N. CREEK DRIVE
LYNWOOD IL
60411
US

V. Phone/Fax

Practice location:
  • Phone: 708-252-0521
  • Fax:
Mailing address:
  • Phone: 708-252-0521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM BRYANT
Title or Position: CEO
Credential: NP
Phone: 708-252-0521