Provider Demographics
NPI:1104204908
Name:MACKENZIE, RYAN JOHN (DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JOHN
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 36TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4741
Mailing Address - Country:US
Mailing Address - Phone:503-540-8701
Mailing Address - Fax:503-371-8772
Practice Address - Street 1:1750 WILCO RD
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1085
Practice Address - Country:US
Practice Address - Phone:503-769-7131
Practice Address - Fax:503-769-7132
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT61006225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist