=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952904435
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK RYAN SAWYER DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2020
-----------------------------------------------------
Last Update Date | 11/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 CONCORD AVE
-----------------------------------------------------
City | CHICO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95928-9487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-879-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5533 HELGA CT
-----------------------------------------------------
City | LIVERMORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94550-8142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-858-2710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 298812
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------