MEDICARE: DOMINIQUE S BRYANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver

General Provider Information

NPI Number	:	1629840350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE S BRYANT

Provider Business Mailing Address
First Line	:	1119 E 74TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44103-1918
Country	:	US
Telephone Number	:	216-224-2021
Fax Number	:

Provider Business Practice Location Address
First Line	:	1119 E 74TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44103-1918
Country	:	US
Telephone Number	:	216-224-2021
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2023
Last Update Date	:	04/02/2025

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Directions to “ DOMINIQUE S BRYANT ” Practice Location

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