Healthcare Provider Details

I. General information

NPI: 1730691148
Provider Name (Legal Business Name): BRYCE FERLAND IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 HOSPITAL LOOP
FAIRCHILD AFB WA
99011-8704
US

IV. Provider business mailing address

1120 5TH ST
MANHATTAN BEACH CA
90266-6004
US

V. Phone/Fax

Practice location:
  • Phone: 916-300-1682
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: