Healthcare Provider Details

I. General information

NPI: 1578961728
Provider Name (Legal Business Name): BRYAN ALLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2014
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 SOUTHBRIDGE DR
JACKSONVILLE NC
28546-7884
US

IV. Provider business mailing address

2006 PELICAN HILL RD
SAN DIEGO CA
92139-1151
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4841
  • Fax:
Mailing address:
  • Phone: 803-236-0332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN-112950
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: