Provider Demographics
NPI:1407534365
Name:BAD HEART BULL, RYAN T (RD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:T
Last Name:BAD HEART BULL
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 E 3RD AVE APT E113
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-8720
Mailing Address - Country:US
Mailing Address - Phone:612-816-6474
Mailing Address - Fax:
Practice Address - Street 1:1455 E 3RD AVE APT E113
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-8720
Practice Address - Country:US
Practice Address - Phone:612-816-6474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered