Healthcare Provider Details

I. General information

NPI: 1023945268
Provider Name (Legal Business Name): RYAN THACKER
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 LOGAN TPKE
GLEN DANIEL WV
25844
US

IV. Provider business mailing address

PO BOX 63
FAIRDALE WV
25839-0063
US

V. Phone/Fax

Practice location:
  • Phone: 304-578-9852
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: