Provider Demographics
NPI:1649518192
Name:DAVENPORT, RYAN KRISTOPHER (LAC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:KRISTOPHER
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 N ARLINGTON HEIGHTS RD
Mailing Address - Street 2:UNIT B
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-3971
Mailing Address - Country:US
Mailing Address - Phone:815-793-4708
Mailing Address - Fax:
Practice Address - Street 1:700 N LAKE ST
Practice Address - Street 2:#102
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1357
Practice Address - Country:US
Practice Address - Phone:847-949-0063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001118171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist