Provider Demographics
NPI:1174550149
Name:SIMMONS, BRYAN D
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:D
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SIMMONS
Other - Middle Name:WELLNESS
Other - Last Name:PRODUCTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:555 S SHORELINE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78401-3552
Mailing Address - Country:US
Mailing Address - Phone:361-887-9456
Mailing Address - Fax:361-887-7300
Practice Address - Street 1:555 S SHORELINE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78401-3552
Practice Address - Country:US
Practice Address - Phone:361-887-9456
Practice Address - Fax:361-887-7300
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2013-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0053646171WH0202X, 332B00000X, 332BC3200X, 247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No171WH0202XOther Service ProvidersContractorHome Modifications
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154894302Medicaid
TX154894303Medicaid
TX154894304Medicaid
TX154894301Medicaid
TX4447160001Medicare NSC
TX154894304Medicaid