Healthcare Provider Details

I. General information

NPI: 1285083097
Provider Name (Legal Business Name): RYAN MIYASHIRO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 HOUBOLT RD
JOLIET IL
60431-9063
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 779-260-2700
  • Fax: 779-260-2701
Mailing address:
  • Phone: 586-350-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070022334
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: