Basic Information
| Provider Information | |||||||||
| NPI: | 1770962904 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKILLEN | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | CARL | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 DEWEY AVE NW | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495047335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163565000 | ||||||||
| FaxNumber: | 6163565001 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 MEXICO RD | ||||||||
| Address2: | STE 104 | ||||||||
| City: | SAINT PETERS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633761666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369399540 | ||||||||
| FaxNumber: | 6369399886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2015 | ||||||||
| LastUpdateDate: | 05/02/2016 | ||||||||
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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 | 225100000X | 2013028736 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 13661377 | 01 | MO | CAQH | OTHER |