Provider Demographics
NPI:1649901760
Name:RYAN, ELTON AUGUSTUS
Entity type:Individual
Prefix:
First Name:ELTON
Middle Name:AUGUSTUS
Last Name:RYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 S ST ANDREWS PL APT 105
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-4414
Mailing Address - Country:US
Mailing Address - Phone:323-356-3572
Mailing Address - Fax:
Practice Address - Street 1:1000 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-8800
Practice Address - Country:US
Practice Address - Phone:626-759-9154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician