Healthcare Provider Details

I. General information

NPI: 1134846512
Provider Name (Legal Business Name): AUSTIN RYDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 E OAK ST
KISSIMMEE FL
34744-4503
US

IV. Provider business mailing address

4135 KAISER AVE
SAINT CLOUD FL
34772-9334
US

V. Phone/Fax

Practice location:
  • Phone: 407-385-0728
  • Fax:
Mailing address:
  • Phone: 321-521-1185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-241184
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: