MEDICARE: RYAN'S WAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility	090000644	CA

General Provider Information

NPI Number	:	1255669404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RYAN'S WAY

Provider Business Mailing Address
First Line	:	PO BOX 212678
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91921-2678
Country	:	US
Telephone Number	:	619-852-3811
Fax Number	:	619-216-0587

Provider Business Practice Location Address
First Line	:	3453 AVELEY PL
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-4727
Country	:	US
Telephone Number	:	858-541-2632
Fax Number	:	858-541-2663

Authorized Official
Title or Position	:	CEO
Name	:	JAMIE O'CONNOR FLOREZ
Credential	:
Telephone Number	:	619-852-3811

Provider Enumeration Date	:	11/30/2009
Last Update Date	:	11/30/2009

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Directions to “RYAN'S WAY ” Practice Location

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