Provider Demographics
NPI:1306036256
Name:RYAN, MAURY FOSTER (LAC)
Entity Type:Individual
Prefix:MR
First Name:MAURY
Middle Name:FOSTER
Last Name:RYAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12114 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3812
Mailing Address - Country:US
Mailing Address - Phone:310-390-7155
Mailing Address - Fax:
Practice Address - Street 1:12114 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-3812
Practice Address - Country:US
Practice Address - Phone:310-390-7155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA7559171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist