Healthcare Provider Details

I. General information

NPI: 1013132869
Provider Name (Legal Business Name): EDWARD DAVIS RYAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 HASTINGS CT
GAINESVILLE GA
30504-2629
US

IV. Provider business mailing address

1626 HASTINGS CT
GAINESVILLE GA
30504-2629
US

V. Phone/Fax

Practice location:
  • Phone: 678-936-0343
  • Fax: 678-450-6931
Mailing address:
  • Phone: 678-936-0343
  • Fax: 678-450-6931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT008101
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: