=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689291684
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIN RYAN MSOM, LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2020
-----------------------------------------------------
Last Update Date | 06/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 457 COVENTRY LN STE 122
-----------------------------------------------------
City | CRYSTAL LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60014-7571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-893-9590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 967 GOLF COURSE RD APT 1
-----------------------------------------------------
City | CRYSTAL LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60014-8809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-403-8289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 198001399
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------