=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235778713
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN FUNKE DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2019
-----------------------------------------------------
Last Update Date | 12/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2283 GRAND ISLAND BLVD
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14072-1819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-773-2222
-----------------------------------------------------
Fax | 866-907-6157
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8311 N HIGH ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43235-6459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-888-9355
-----------------------------------------------------
Fax | 614-888-9356
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 013333
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------