Provider Demographics
NPI:1548267792
Name:BRYAN, CHRIS WILLIAM (DC)
Entity type:Individual
Prefix:DR
First Name:CHRIS
Middle Name:WILLIAM
Last Name:BRYAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5003
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46546-5003
Mailing Address - Country:US
Mailing Address - Phone:574-259-3355
Mailing Address - Fax:574-259-2032
Practice Address - Street 1:236 W EDISON RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3184
Practice Address - Country:US
Practice Address - Phone:574-259-3355
Practice Address - Fax:574-259-2032
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN772111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN737940Medicare ID - Type Unspecified
INT35011Medicare UPIN