Healthcare Provider Details

I. General information

NPI: 1083037303
Provider Name (Legal Business Name): RYAN ANTHONY FRAILEY DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 110C
ELIZABETHTOWN IL
62931-9708
US

IV. Provider business mailing address

RR 1 BOX 110C
ELIZABETHTOWN IL
62931-9708
US

V. Phone/Fax

Practice location:
  • Phone: 618-285-4455
  • Fax: 618-285-4458
Mailing address:
  • Phone: 618-285-4455
  • Fax: 618-285-4458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038012583
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: