Healthcare Provider Details

I. General information

NPI: 1154232882
Provider Name (Legal Business Name): RYAN CHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 REDSTONE AVE W STE 100
CRESTVIEW FL
32536-6429
US

IV. Provider business mailing address

403 DELLCREST DR
FOREST HILL MD
21050-2806
US

V. Phone/Fax

Practice location:
  • Phone: 850-683-5906
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: