Provider Demographics
NPI:1922410786
Name:RIDLEY, COREY M (ATC)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:M
Last Name:RIDLEY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 PARIS RD
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:ME
Mailing Address - Zip Code:04238-3414
Mailing Address - Country:US
Mailing Address - Phone:207-212-2185
Mailing Address - Fax:
Practice Address - Street 1:77 BATES ST
Practice Address - Street 2:SUITE 201
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7637
Practice Address - Country:US
Practice Address - Phone:207-795-8465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT2032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer