Healthcare Provider Details

I. General information

NPI: 1710866611
Provider Name (Legal Business Name): RYAN FLYNN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 43RD ST SE STE 100
GRAND RAPIDS MI
49508-3712
US

IV. Provider business mailing address

2120 43RD ST SE STE 100
GRAND RAPIDS MI
49508-3712
US

V. Phone/Fax

Practice location:
  • Phone: 616-281-1144
  • Fax:
Mailing address:
  • Phone: 616-281-1144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501303848
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: