Healthcare Provider Details

I. General information

NPI: 1912128471
Provider Name (Legal Business Name): YONGKI COLIN RYU DC, MS, ICCSP, DGCSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 PROSPECT AVE.
RIDGEFIELD NJ
07657-1712
US

IV. Provider business mailing address

633 PROSPECT AVE.
RIDGEFIELD NJ
07657-1712
US

V. Phone/Fax

Practice location:
  • Phone: 201-313-0321
  • Fax:
Mailing address:
  • Phone: 201-313-0321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038-010717
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number06861
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number011408
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number001720
License Number StateCT
# 5
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number38MC00659900
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX-011408-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: