Healthcare Provider Details

I. General information

NPI: 1750193355
Provider Name (Legal Business Name): BRIAN BRISTEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7151 WALTON ST
ROCKFORD IL
61108-2600
US

IV. Provider business mailing address

7151 WALTON ST
ROCKFORD IL
61108-2600
US

V. Phone/Fax

Practice location:
  • Phone: 815-229-9037
  • Fax:
Mailing address:
  • Phone: 815-229-9037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2390
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: