Basic Information
Provider Information
NPI: 1174612378
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: O'BRYANT
FirstName: GREGORY
MiddleName: KARL
NamePrefix: DR.
NameSuffix:  
Credential: D.C.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 218 E 800 S
Address2:  
City: OREM
State: UT
PostalCode: 840585008
CountryCode: US
TelephoneNumber: 8012252457
FaxNumber: 8012252537
Practice Location
Address1: 218 E 800 S
Address2:  
City: OREM
State: UT
PostalCode: 840585008
CountryCode: US
TelephoneNumber: 8012252457
FaxNumber: 8012252537
Other Information
ProviderEnumerationDate: 10/12/2006
LastUpdateDate: 10/03/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
111N00000X5616019-1202UTY Chiropractic ProvidersChiropractor 

No ID Information.


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