1679618706 NPI number — MR. RYAN SCOTT STEVENS MPS, ATC, CSCS

Table of content: MR. RYAN SCOTT STEVENS MPS, ATC, CSCS (NPI 1679618706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679618706 NPI number — MR. RYAN SCOTT STEVENS MPS, ATC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENS
Provider First Name:
RYAN
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MPS, ATC, CSCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679618706
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 REHILL AVE
Provider Second Line Business Mailing Address:
ATTN: SPORTS PERFORMANCE & REHABILITATION CENTER
Provider Business Mailing Address City Name:
SOMERVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08876-2519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-203-5972
Provider Business Mailing Address Fax Number:
908-685-2413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 PATRIOTS PARK
Provider Second Line Business Practice Location Address:
TD BANK BALLPARK
Provider Business Practice Location Address City Name:
BRIDGEWATER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08807-3454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-203-5972
Provider Business Practice Location Address Fax Number:
908-685-2413
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  001366 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2255A2300X , with the licence number: 25MT00157800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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