=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124674171
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RYKEN-NDFC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2019
-----------------------------------------------------
Last Update Date | 08/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1760 E PECOS RD STE 532
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-3210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-590-1380
-----------------------------------------------------
Fax | 480-857-2036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1760 E PECOS RD STE 532
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-3210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-590-1380
-----------------------------------------------------
Fax | 480-857-2036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR OF CHIROPRACTIC/OWNER
-----------------------------------------------------
Name | DR. RYAN HICKS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 480-857-1991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------