Healthcare Provider Details

I. General information

NPI: 1316212806
Provider Name (Legal Business Name): JACLYN GRACE RYKAL AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 LA CANADA ST
LAS VEGAS NV
89169-2578
US

IV. Provider business mailing address

650 S TOWN CENTER DR APARTMENT #2111
LAS VEGAS NV
89144-4419
US

V. Phone/Fax

Practice location:
  • Phone: 702-636-3059
  • Fax:
Mailing address:
  • Phone: 715-222-5036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number000727
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: