Provider Demographics
NPI:1295175024
Name:ANDERSON, RYAN ROGER (DC)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:ROGER
Last Name:ANDERSON
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 1:653 CAMINO DE LOS MARES STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2808
Mailing Address - Country:US
Mailing Address - Phone:949-284-6620
Mailing Address - Fax:949-284-0598
Practice Address - Street 1:653 CAMINO DE LOS MARES STE 100
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2808
Practice Address - Country:US
Practice Address - Phone:949-284-6620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32637111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor