Healthcare Provider Details

I. General information

NPI: 1972633998
Provider Name (Legal Business Name): RYAN E NEAULT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 BOULEVARD # 999
ANDERSON SC
29621-4002
US

IV. Provider business mailing address

316 BOULEVARD # 999
ANDERSON SC
29621-4002
US

V. Phone/Fax

Practice location:
  • Phone: 864-231-2144
  • Fax: 864-622-6059
Mailing address:
  • Phone: 864-231-2144
  • Fax: 864-622-6059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number734
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: