Basic Information
| Provider Information | |||||||||
| NPI: | 1295117174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | STEVEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1947 N CALIFORNIA ST | ||||||||
| Address2: | B | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952046029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094630870 | ||||||||
| FaxNumber: | 2094631003 | ||||||||
| Practice Location | |||||||||
| Address1: | 1947 N CALIFORNIA ST | ||||||||
| Address2: | B | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952046029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094630870 | ||||||||
| FaxNumber: | 2094631903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2015 | ||||||||
| LastUpdateDate: | 10/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 00-85-020-0517 | CA | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.