Provider Demographics
NPI:1720354558
Name:RYLL, JOHN DAVID
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:RYLL
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 1:900 SHIP POND RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-1849
Mailing Address - Country:US
Mailing Address - Phone:617-686-7901
Mailing Address - Fax:
Practice Address - Street 1:900 SHIP POND RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-1849
Practice Address - Country:US
Practice Address - Phone:617-686-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA322D00000X322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children