Healthcare Provider Details

I. General information

NPI: 1487427316
Provider Name (Legal Business Name): RYAN CHRENCIK OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12910 SHELBYVILLE RD STE 300
LOUISVILLE KY
40243-2404
US

IV. Provider business mailing address

5769 BENT TREE DR
GAYLORD MI
49735-7604
US

V. Phone/Fax

Practice location:
  • Phone: 855-259-9183
  • Fax:
Mailing address:
  • Phone: 989-350-7702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005742
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: