Provider Demographics
NPI:1801858998
Name:RYAN, BRENT ROGERS (ATC/L)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:ROGERS
Last Name:RYAN
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5125 HICKORY VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-3773
Mailing Address - Country:US
Mailing Address - Phone:931-738-8760
Mailing Address - Fax:
Practice Address - Street 1:2335 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4889
Practice Address - Country:US
Practice Address - Phone:931-520-2287
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer