Provider Demographics
NPI:1275149320
Name:RIDDLE, ZACHARY REAGAN (LMT)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:REAGAN
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 COPPER RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:ROCKVALE
Mailing Address - State:TN
Mailing Address - Zip Code:37153-4655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 COPPER RIDGE TRL
Practice Address - Street 2:
Practice Address - City:ROCKVALE
Practice Address - State:TN
Practice Address - Zip Code:37153-4655
Practice Address - Country:US
Practice Address - Phone:615-653-9620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000006984225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty