Healthcare Provider Details

I. General information

NPI: 1962463653
Provider Name (Legal Business Name): RYAN LEE SCHALLENBERG PT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 S 6TH ST
SPRINGFIELD IL
62703-5915
US

IV. Provider business mailing address

1025 S 6TH ST
SPRINGFIELD IL
62703-2403
US

V. Phone/Fax

Practice location:
  • Phone: 217-528-7541
  • Fax: 217-789-2569
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096001542
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070014692
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: