=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225678691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRYVIC MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2020
-----------------------------------------------------
Last Update Date | 01/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1914 FALCON RIDGE DR
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80528-5100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-217-4896
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1914 FALCON RIDGE DR
-----------------------------------------------------
City | FORT COLLINS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80528-5100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-217-4896
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER / OWNER
-----------------------------------------------------
Name | VICTOR DUARTE
-----------------------------------------------------
Credential | FNP-C, WCC
-----------------------------------------------------
Telephone | 970-217-4896
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------