Provider Demographics
NPI:1609605500
Name:DUNN, RYAN EDWARD
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:EDWARD
Last Name:DUNN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22650 LOST RD
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-8391
Mailing Address - Country:US
Mailing Address - Phone:951-566-6154
Mailing Address - Fax:
Practice Address - Street 1:22650 LOST RD
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-8391
Practice Address - Country:US
Practice Address - Phone:951-566-6154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA330221AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility