Healthcare Provider Details

I. General information

NPI: 1497208904
Provider Name (Legal Business Name): JARVIS RYALS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2016
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 IRONWEED DR
PUEBLO CO
81001-1048
US

IV. Provider business mailing address

84 IRONWEED DR
PUEBLO CO
81001-1048
US

V. Phone/Fax

Practice location:
  • Phone: 719-250-3513
  • Fax:
Mailing address:
  • Phone: 719-250-3513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number0020063
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: