Provider Demographics
NPI:1750705323
Name:RYAN O'MALLEY LLC
Entity type:Organization
Organization Name:RYAN O'MALLEY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FORMER OM
Authorized Official - Prefix:
Authorized Official - First Name:IVEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDSAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-962-4140
Mailing Address - Street 1:419 SE MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-2673
Mailing Address - Country:US
Mailing Address - Phone:864-962-4140
Mailing Address - Fax:864-962-4142
Practice Address - Street 1:419 SE MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-2673
Practice Address - Country:US
Practice Address - Phone:864-962-4140
Practice Address - Fax:864-962-4142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6921332BC3200X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831503580OtherINDIVIDUAL NPI
SC1710290663OtherINDIVIDUAL NPI