Healthcare Provider Details

I. General information

NPI: 1992437842
Provider Name (Legal Business Name): RYAN RICHARD CLEMENTS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 E TAMPA ST
SPRINGFIELD MO
65806-1131
US

IV. Provider business mailing address

440 E TAMPA ST
SPRINGFIELD MO
65806-1131
US

V. Phone/Fax

Practice location:
  • Phone: 417-851-1551
  • Fax: 417-832-8275
Mailing address:
  • Phone: 417-851-1551
  • Fax: 417-832-8275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2019019567
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: