Healthcare Provider Details

I. General information

NPI: 1649772815
Provider Name (Legal Business Name): MR. ZACHARY D RYDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 03/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11910 BOYETTE RD
RIVERVIEW FL
33569-5601
US

IV. Provider business mailing address

550 N REO ST STE 202
TAMPA FL
33609-1062
US

V. Phone/Fax

Practice location:
  • Phone: 813-374-2070
  • Fax:
Mailing address:
  • Phone: 813-374-2070
  • Fax: 813-337-0937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: