Healthcare Provider Details

I. General information

NPI: 1376636621
Provider Name (Legal Business Name): RYAN BRANSTETTER MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E VINE ST
MURFREESBORO TN
37130-3734
US

IV. Provider business mailing address

3122 S MONROE AVE
JOPLIN MO
64804-1451
US

V. Phone/Fax

Practice location:
  • Phone: 417-622-8369
  • Fax:
Mailing address:
  • Phone: 471-622-8369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number2004030105
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: