Provider Demographics
NPI:1043371610
Name:RIDGEWAY, DARYL LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:DARYL
Middle Name:LEE
Last Name:RIDGEWAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 MAIN PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-1170
Mailing Address - Country:US
Mailing Address - Phone:636-639-8944
Mailing Address - Fax:
Practice Address - Street 1:1023 MAIN PLAZA DR
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-1170
Practice Address - Country:US
Practice Address - Phone:636-639-8944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006613111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO613474769Medicare PIN
MO000014769Medicare PIN