Healthcare Provider Details

I. General information

NPI: 1306364617
Provider Name (Legal Business Name): JOHN GAGE RYDER MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 11/05/2022
Certification Date: 11/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 GRAND CENTRAL AVE
VIENNA WV
26105-1081
US

IV. Provider business mailing address

1605 GRAND CENTRAL AVE
VIENNA WV
26105-1081
US

V. Phone/Fax

Practice location:
  • Phone: 304-295-7290
  • Fax: 304-295-5922
Mailing address:
  • Phone: 304-295-7290
  • Fax: 304-295-5922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000020739
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT004414
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: