Provider Demographics
NPI:1184796062
Name:RYAN, KEVIN PETER (DC,CCSP)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:PETER
Last Name:RYAN
Suffix:
Gender:M
Credentials:DC,CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7151 EL CAJON BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-1819
Mailing Address - Country:US
Mailing Address - Phone:619-466-5858
Mailing Address - Fax:619-466-9814
Practice Address - Street 1:7151 EL CAJON BLVD STE J
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-1819
Practice Address - Country:US
Practice Address - Phone:619-466-5858
Practice Address - Fax:619-466-9814
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC16045111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT82621Medicare ID - Type Unspecified
CA16045Medicare UPIN