Provider Demographics
NPI:1609316405
Name:RIVARD, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:RIVARD
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 1:1602 JENNIFER RD APT 23
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40505-3010
Mailing Address - Country:US
Mailing Address - Phone:859-227-6663
Mailing Address - Fax:
Practice Address - Street 1:324 SOUTHVIEW DR
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-2008
Practice Address - Country:US
Practice Address - Phone:859-227-6663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid