Healthcare Provider Details

I. General information

NPI: 1457725608
Provider Name (Legal Business Name): RYAN CARD OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2015
Last Update Date: 11/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 KINGSLEY AVE
ORANGE PARK FL
32073-4631
US

IV. Provider business mailing address

101 LITTLE POND WAY
ST AUGUSTINE FL
32086-3002
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-8922
  • Fax:
Mailing address:
  • Phone: 973-903-3439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT15472
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: