Healthcare Provider Details

I. General information

NPI: 1285364950
Provider Name (Legal Business Name): RYAN SCOTT SELF PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8055 FARMINGDALE RD
GERMANTOWN TN
38138-2347
US

IV. Provider business mailing address

4337 W OXFORD ST
CEDAR HILLS UT
84062-8638
US

V. Phone/Fax

Practice location:
  • Phone: 803-602-8086
  • Fax:
Mailing address:
  • Phone: 801-822-1880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11635
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: