Provider Demographics
NPI:1578109476
Name:RIDEOUT, GARY LOYD SR
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LOYD
Last Name:RIDEOUT
Suffix:SR
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 1:5300 CHARLES CT
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-9255
Mailing Address - Country:US
Mailing Address - Phone:501-952-9774
Mailing Address - Fax:
Practice Address - Street 1:5300 CHARLES CT
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022-9255
Practice Address - Country:US
Practice Address - Phone:501-952-9774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)