Provider Demographics
NPI:1083037303
Name:FRAILEY, RYAN ANTHONY (DC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ANTHONY
Last Name:FRAILEY
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:RR 1 BOX 110C
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62931-9708
Mailing Address - Country:US
Mailing Address - Phone:618-285-4455
Mailing Address - Fax:618-285-4458
Practice Address - Street 1:RR 1 BOX 110C
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:IL
Practice Address - Zip Code:62931-9708
Practice Address - Country:US
Practice Address - Phone:618-285-4455
Practice Address - Fax:618-285-4458
Is Sole Proprietor?:No
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012583111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor