Provider Demographics
NPI:1043690852
Name:WITHOLT, RYAN (LMT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WITHOLT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6222 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-1455
Mailing Address - Country:US
Mailing Address - Phone:702-505-1494
Mailing Address - Fax:
Practice Address - Street 1:4005 S EL CAPITAN WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-3430
Practice Address - Country:US
Practice Address - Phone:170-275-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3291225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist