Healthcare Provider Details

I. General information

NPI: 1740599182
Provider Name (Legal Business Name): TERRI RYBAK CST/CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2010
Last Update Date: 08/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3493 LOWER BURRIS RD
CANTON GA
30114-4755
US

IV. Provider business mailing address

3493 LOWER BURRIS RD
CANTON GA
30114-4755
US

V. Phone/Fax

Practice location:
  • Phone: 770-331-4217
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: