Provider Demographics
NPI:1528134178
Name:RYAN CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:RYAN CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:W
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:315-539-3262
Mailing Address - Street 1:PO BOX 664
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165
Mailing Address - Country:US
Mailing Address - Phone:315-539-3262
Mailing Address - Fax:315-539-5221
Practice Address - Street 1:2374 MOUND RD RTE 414
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165
Practice Address - Country:US
Practice Address - Phone:315-539-3262
Practice Address - Fax:315-539-5221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0061021111N00000X
NYX010083111N00000X
NYX0054062111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5211586OtherAETNA
7153201OtherAETNA
101869ANOtherPREFERRED CARE
101865ANOtherPREFERRED CARE
NY14552BMedicare PIN
5211586OtherAETNA
NYU11429Medicare UPIN
NYCC9340Medicare PIN
7153201OtherAETNA
NY14552AMedicare PIN
NYU84876Medicare UPIN