Provider Demographics
NPI:1760403273
Name:RIEDEL, JAY B (DC)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:B
Last Name:RIEDEL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:OH
Mailing Address - Zip Code:44041-1385
Mailing Address - Country:US
Mailing Address - Phone:440-466-1155
Mailing Address - Fax:440-466-1255
Practice Address - Street 1:614 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:OH
Practice Address - Zip Code:44041-1385
Practice Address - Country:US
Practice Address - Phone:440-466-1155
Practice Address - Fax:440-466-1255
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3328111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00199838OtherRAILROAD MEDICARE
OHP00199838OtherRAILROAD MEDICARE