=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124702113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RYAN SWANSON LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2023
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 BUSCH PKWY
-----------------------------------------------------
City | BUFFALO GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60089-2686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-912-4948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 985 HALF DAY RD
-----------------------------------------------------
City | HIGHLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60035-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-912-4948
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | RYAN SWANSON
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 847-912-4948
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------