Healthcare Provider Details

I. General information

NPI: 1346671179
Provider Name (Legal Business Name): RYAN LYSTAD D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2013
Last Update Date: 12/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 S BROADWAY
DENVER CO
80210-2204
US

IV. Provider business mailing address

1361 S BROADWAY
DENVER CO
80210-2204
US

V. Phone/Fax

Practice location:
  • Phone: 720-541-7098
  • Fax:
Mailing address:
  • Phone: 720-541-7098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHR.0007052
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: