Healthcare Provider Details

I. General information

NPI: 1699719856
Provider Name (Legal Business Name): BRYAN JAMES PAINTER ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW BUCHANAN AVE
CORVALLIS OR
97330-5838
US

IV. Provider business mailing address

3088 27TH AVE SE
ALBANY OR
97322-9592
US

V. Phone/Fax

Practice location:
  • Phone: 541-757-4455
  • Fax:
Mailing address:
  • Phone: 541-791-9281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAT-AT-317841
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: