Healthcare Provider Details

I. General information

NPI: 1083008858
Provider Name (Legal Business Name): RYAN MONTGOMERY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5605 100TH ST SW STE B
LAKEWOOD WA
98499-2710
US

IV. Provider business mailing address

2463 S M 30
WEST BRANCH MI
48661-9312
US

V. Phone/Fax

Practice location:
  • Phone: 253-284-9800
  • Fax:
Mailing address:
  • Phone: 989-343-3354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60741555
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015209
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: