Healthcare Provider Details

I. General information

NPI: 1710396874
Provider Name (Legal Business Name): BRYAN CREIDLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2014
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 PEMBERTON HILL RD SUITE 201
APEX NC
27502-4267
US

IV. Provider business mailing address

1910 N CHURCH ST SUITE D
GREENSBORO NC
27405-5666
US

V. Phone/Fax

Practice location:
  • Phone: 919-363-3640
  • Fax: 919-363-3642
Mailing address:
  • Phone: 336-274-7480
  • Fax: 336-274-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15087
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: