Provider Demographics
NPI:1598304321
Name:DALE, RYAN (DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DALE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 E JAMES COURT DR STE A
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-8751
Mailing Address - Country:US
Mailing Address - Phone:208-895-0715
Mailing Address - Fax:208-895-0746
Practice Address - Street 1:50 E JAMES COURT DR STE A
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-8751
Practice Address - Country:US
Practice Address - Phone:208-895-0715
Practice Address - Fax:208-895-0746
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6563225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist