Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 31432 | CA |
NPI | 1003190687 |
---|---|
Provider Name | Ryan Maynard |
First Address | Alpine, CA 91901-2930 |
Second Address | Alpine, CA 91901-2930 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/09/2011 |
Last Update Date | 30/09/2011 |