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General NPI Number Information
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NPI Number | 1780143354
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Entity Type | Individual
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Provider Name | RYAN TAYLOR FAIRCLOTH
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Gender | Male
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Dates
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Enumeration Date | 03/13/2019
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Last Update Date | 03/13/2019
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Provider Practice Location Address
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Address Line | 3139 US HIGHWAY 19 NE
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City | PELHAM
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State | GA
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Zip | 31779-5391
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Country | US
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Telephone | 229-319-5145
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Fax |
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Provider Business Mailing Address
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Address Line | 3139 US HIGHWAY 19 NE
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City | PELHAM
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State | GA
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Zip | 31779-5391
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Country | US
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Telephone | 229-319-5145
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA004184
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License Number State | GA
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