Provider Demographics
NPI:1003190687
Name:MAYNARD, RYAN (DC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1937 LILAC LN
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-2930
Mailing Address - Country:US
Mailing Address - Phone:619-990-0880
Mailing Address - Fax:
Practice Address - Street 1:1937 LILAC LN
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-2930
Practice Address - Country:US
Practice Address - Phone:619-990-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31432111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor