Healthcare Provider Details

I. General information

NPI: 1720241847
Provider Name (Legal Business Name): RYAN MARTIN COPPAGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7171 BOWLING DR STE 300
SACRAMENTO CA
95823-2043
US

IV. Provider business mailing address

4343 WILLIAMSBOURGH DR
SACRAMENTO CA
95823
US

V. Phone/Fax

Practice location:
  • Phone: 916-394-9195
  • Fax:
Mailing address:
  • Phone: 916-395-3552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: