Healthcare Provider Details

I. General information

NPI: 1992380455
Provider Name (Legal Business Name): RYAN DANIEL MCCULLOUGH PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/16/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 INDUSTRIAL DRIVE
ASH FLAT AR
72513
US

IV. Provider business mailing address

291 EMERSON DR.
VIOLET HILL AR
72584
US

V. Phone/Fax

Practice location:
  • Phone: 501-352-6105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4615
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: