Provider Demographics
NPI:1962189175
Name:LUIS, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:LUIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7439 VALARIA DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-3450
Mailing Address - Country:US
Mailing Address - Phone:909-362-3982
Mailing Address - Fax:
Practice Address - Street 1:6876 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2860
Practice Address - Country:US
Practice Address - Phone:760-992-3039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician