Provider Demographics
NPI:1285026930
Name:RIDENOUR, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:RIDENOUR
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 1:600 CENTRAL AVE SE STE D
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-4650
Mailing Address - Country:US
Mailing Address - Phone:505-242-4494
Mailing Address - Fax:
Practice Address - Street 1:348 WARFIELD BLVD.
Practice Address - Street 2:SUITES C AND D
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043
Practice Address - Country:US
Practice Address - Phone:931-906-4170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-03
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4235225100000X
TN11417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist