Provider Demographics
NPI:1659439081
Name:GULLETT, RYAN AUGUST (DC)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:AUGUST
Last Name:GULLETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 W ERNESTINE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5800
Mailing Address - Country:US
Mailing Address - Phone:618-997-3257
Mailing Address - Fax:
Practice Address - Street 1:3905 W ERNESTINE DR
Practice Address - Street 2:SUITE B
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5800
Practice Address - Country:US
Practice Address - Phone:618-997-3257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9278111N00000X
IL038011259111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor