Provider Demographics
NPI:1174104905
Name:BRYZACON LLC
Entity type:Organization
Organization Name:BRYZACON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IKENGAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-847-0488
Mailing Address - Street 1:16015 CRESTED GREEN DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-4086
Mailing Address - Country:US
Mailing Address - Phone:832-847-4880
Mailing Address - Fax:
Practice Address - Street 1:2235 E FLAMINGO RD STE 150
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5198
Practice Address - Country:US
Practice Address - Phone:832-847-0488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)