Healthcare Provider Details

I. General information

NPI: 1740851575
Provider Name (Legal Business Name): BRYAN CHRISTOPHER ORT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2021
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11103 WEST AVE STE 108
SAN ANTONIO TX
78213-4915
US

IV. Provider business mailing address

11103 WEST AVE STE 108
SAN ANTONIO TX
78213-4915
US

V. Phone/Fax

Practice location:
  • Phone: 210-340-2627
  • Fax:
Mailing address:
  • Phone: 210-340-2627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-171633
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: