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General NPI Number Information
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NPI Number | 1124663539
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Entity Type | Individual
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Provider Name | RYAN HORTUM OTR/L
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Gender | Male
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Dates
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Enumeration Date | 11/08/2019
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Last Update Date | 11/08/2019
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Provider Practice Location Address
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Address Line | 975 S FAIRMONT AVE
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City | LODI
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State | CA
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Zip | 95240-5118
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Country | US
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Telephone | 209-333-3100
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Fax |
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Provider Business Mailing Address
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Address Line | 440 HERITAGE LN
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City | DIXON
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State | CA
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Zip | 95620-4890
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Country | US
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Telephone | 707-338-6550
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 16285
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License Number State | CA
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