Healthcare Provider Details

I. General information

NPI: 1811626419
Provider Name (Legal Business Name): RYAN DIVITA TEACHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 SAN FERNANDO LN
EAST AMHERST NY
14051-2234
US

IV. Provider business mailing address

153 BRAMBLE CT
WILLIAMSVILLE NY
14221-1715
US

V. Phone/Fax

Practice location:
  • Phone: 716-472-1289
  • Fax: 716-689-2916
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: