Healthcare Provider Details

I. General information

NPI: 1881120103
Provider Name (Legal Business Name): BRYAN GOTTSHALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 SMITH REED RD
LAFAYETTE LA
70507-2605
US

IV. Provider business mailing address

PO BOX 187
CARENCRO LA
70520-0187
US

V. Phone/Fax

Practice location:
  • Phone: 255-239-2301
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: