Basic Information
| Provider Information | |||||||||
| NPI: | 1447613997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALDWELL | ||||||||
| FirstName: | RYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3536 SHADY ROCK DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809207300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193101578 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 COLCHESTER AVE # 222WP2 | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028472700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2016 | ||||||||
| LastUpdateDate: | 04/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.