Provider Demographics
NPI:1518297027
Name:RIDDLE, KEVIN (CMT, LMT, LMTI)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:CMT, LMT, LMTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 LINDEN AVE APT A
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-1549
Mailing Address - Country:US
Mailing Address - Phone:303-249-1054
Mailing Address - Fax:
Practice Address - Street 1:1240 LINDEN AVE APT A
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-1549
Practice Address - Country:US
Practice Address - Phone:303-249-1054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5170225700000X
CO8934225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist