Basic Information
| Provider Information | |||||||||
| NPI: | 1346731056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | ORIN | ||||||||
| MiddleName: | KELLEY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 FALLS AVE E STE 415 | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 N STATE ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | SHELLEY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832744900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087824744 | ||||||||
| FaxNumber: | 2089061554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2018 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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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 | 225100000X | PT-5567 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.