Provider Demographics
NPI:1538498845
Name:RIDER ATHLETIC ADVANTAGE
Entity Type:Organization
Organization Name:RIDER ATHLETIC ADVANTAGE
Other - Org Name:ATHLETIC ADVANTAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:214-383-2614
Mailing Address - Street 1:820 S ALMA DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-3808
Mailing Address - Country:US
Mailing Address - Phone:214-383-2641
Mailing Address - Fax:214-383-9534
Practice Address - Street 1:820 S ALMA DR
Practice Address - Street 2:SUITE 110
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-3808
Practice Address - Country:US
Practice Address - Phone:214-383-0623
Practice Address - Fax:214-383-9534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX667260000261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy