Provider Demographics
NPI:1467917617
Name:RYDBOM, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:RYDBOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 CANE BAY BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-2397
Mailing Address - Country:US
Mailing Address - Phone:843-719-7473
Mailing Address - Fax:843-279-3251
Practice Address - Street 1:1655 CANE BAY BLVD STE B
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-2397
Practice Address - Country:US
Practice Address - Phone:843-719-7473
Practice Address - Fax:843-279-3251
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant