Healthcare Provider Details

I. General information

NPI: 1851984371
Provider Name (Legal Business Name): RYAN MOODY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2021
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 ELMWOOD AVE STE 130
ROCHESTER NY
14620-3428
US

IV. Provider business mailing address

PO BOX 725
MENDON NY
14506-0725
US

V. Phone/Fax

Practice location:
  • Phone: 585-442-9110
  • Fax: 585-442-9049
Mailing address:
  • Phone: 585-582-6273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number046600
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: