Provider Demographics
NPI:1104208040
Name:SUMMERS, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:SUMMERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:16515 MERIDIAN E
Practice Address - Street 2:SUITE 202B
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-6251
Practice Address - Country:US
Practice Address - Phone:253-840-5511
Practice Address - Fax:253-840-0835
Is Sole Proprietor?:No
Enumeration Date:2015-06-27
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60721468225100000X
OH015480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist