Provider Demographics
NPI:1639360720
Name:RIDDEL CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:RIDDEL CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:STEWART
Authorized Official - Last Name:RIDDEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:925-345-7890
Mailing Address - Street 1:3147 PUTNAM BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-4686
Mailing Address - Country:US
Mailing Address - Phone:925-945-7890
Mailing Address - Fax:
Practice Address - Street 1:3147 PUTNAM BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4686
Practice Address - Country:US
Practice Address - Phone:925-945-7890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. JOHN S RIDDEL, D.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16829111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical ExaminerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0168290Medicare PIN