MEDICARE: RYLE GARLAND ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	LAT-4055	NC

General Provider Information

NPI Number	:	1811543549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYLE GARLAND ATC

Provider Business Mailing Address
First Line	:	606 W CHURCH ST
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-4726
Country	:	US
Telephone Number	:	252-335-3523
Fax Number	:

Provider Business Practice Location Address
First Line	:	1704 WEEKSVILLE RD
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-7977
Country	:	US
Telephone Number	:	623-363-7720
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2019
Last Update Date	:	08/19/2019

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