Healthcare Provider Details

I. General information

NPI: 1720314966
Provider Name (Legal Business Name): BRYAN FALLIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CHAMBER CENTER DR SUITE 100
LAKESIDE PARK KY
41017-1673
US

IV. Provider business mailing address

PO BOX 636389
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-331-2440
  • Fax: 859-331-2449
Mailing address:
  • Phone: 859-557-4260
  • Fax: 513-557-3347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number00258
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: BRYAN V FALLIS
Title or Position: OWNER
Credential: DPM
Phone: 859-331-2440