Provider Demographics
NPI:1588908859
Name:PACK, RYAN SAMUEL
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:SAMUEL
Last Name:PACK
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 1:107 CARIBOU PL
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-1206
Mailing Address - Country:US
Mailing Address - Phone:303-590-4969
Mailing Address - Fax:
Practice Address - Street 1:500 9TH AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-4598
Practice Address - Country:US
Practice Address - Phone:303-590-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2746225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist