Provider Demographics
NPI:1679334270
Name:BUSH, BRIAN K (RN,BSN)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:BUSH
Suffix:
Gender:M
Credentials:RN,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 RUSTIN AVE BLDG 3
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2498
Mailing Address - Country:US
Mailing Address - Phone:951-955-2105
Mailing Address - Fax:
Practice Address - Street 1:12054 CLARK ST APT 101
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-8652
Practice Address - Country:US
Practice Address - Phone:630-697-2166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95176298163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)