Provider Demographics
NPI:1780643452
Name:RYAN, RANDOLPH RAYMOND (DC)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:RAYMOND
Last Name:RYAN
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 1:21 W. FEE AVE.
Mailing Address - Street 2:SUITE A
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901
Mailing Address - Country:US
Mailing Address - Phone:321-723-5015
Mailing Address - Fax:321-723-7389
Practice Address - Street 1:21 W. FEE AVE.
Practice Address - Street 2:SUITE A
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-723-5015
Practice Address - Fax:321-723-7389
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0005773111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL050580300Medicaid
T85318Medicare UPIN
FL22253Medicare PIN