Provider Demographics
NPI:1649391434
Name:RIEDEL, LAURA BREWER (CPO)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BREWER
Last Name:RIEDEL
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 CRUTCHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2725
Mailing Address - Country:US
Mailing Address - Phone:919-471-4994
Mailing Address - Fax:919-471-4995
Practice Address - Street 1:314 CRUTCHFIELD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2725
Practice Address - Country:US
Practice Address - Phone:919-471-4994
Practice Address - Fax:919-471-4995
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795142Medicaid
NC4215300001Medicare NSC
NC7795142Medicaid