Provider Demographics
NPI:1114481975
Name:RIDGLEY, KEVIN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:CHRISTOPHER
Last Name:RIDGLEY
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 1:5804 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-6842
Mailing Address - Country:US
Mailing Address - Phone:509-570-2394
Mailing Address - Fax:
Practice Address - Street 1:9720 N NEVADA ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218
Practice Address - Country:US
Practice Address - Phone:509-464-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60281143225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60281143OtherMASSAGE LICENSE