Healthcare Provider Details

I. General information

NPI: 1487324372
Provider Name (Legal Business Name): RYAN COMBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 CUMBERLAND AVE STE 225
WEST LAFAYETTE IN
47906-1343
US

IV. Provider business mailing address

1305 CUMBERLAND AVE STE 225
WEST LAFAYETTE IN
47906-1343
US

V. Phone/Fax

Practice location:
  • Phone: 866-672-4764
  • Fax:
Mailing address:
  • Phone: 866-672-4764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: