Healthcare Provider Details

I. General information

NPI: 1578863700
Provider Name (Legal Business Name): BRYAN WALL BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15518 NE FARGHER LAKE HWY
YACOLT WA
98675-4508
US

IV. Provider business mailing address

26916 NE 434TH ST
AMBOY WA
98601-4636
US

V. Phone/Fax

Practice location:
  • Phone: 360-263-4000
  • Fax:
Mailing address:
  • Phone: 360-247-6590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA 00004733
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS-P-509154
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: