Provider Demographics
NPI:1508423500
Name:COLLINS, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:COLLINS
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 1:109 JENNYMAC CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-6081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:76 LOU GROZA BLVD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-1238
Practice Address - Country:US
Practice Address - Phone:502-644-8138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer