Provider Demographics
NPI:1417479080
Name:REIST, RYAN BRADLEY (RD, CSSD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:BRADLEY
Last Name:REIST
Suffix:
Gender:M
Credentials:RD, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 ADDISON DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5392
Mailing Address - Country:US
Mailing Address - Phone:972-897-2460
Mailing Address - Fax:
Practice Address - Street 1:2601 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5602
Practice Address - Country:US
Practice Address - Phone:716-560-2896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015027208133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered