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General NPI Number Information
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NPI Number | 1629673009
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Entity Type | Individual
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Provider Name | RYLAN RUSSELL MASSAGE THERAPIST
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Gender | Male
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Dates
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Enumeration Date | 12/02/2020
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Last Update Date | 12/02/2020
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Provider Practice Location Address
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Address Line | 2602 N. 400 E, LOWER LEVEL #5 LOWER LEVEL #5
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City | NORTH OGDEN
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State | UT
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Zip | 84414-8441
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Country | US
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Telephone | 801-392-1767
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Fax |
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Provider Business Mailing Address
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Address Line | 2602 N 400 E LOWR LEVEL
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City | NORTH OGDEN
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State | UT
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Zip | 84414-2243
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Country | US
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Telephone | 801-392-1767
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State | UT
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