Provider Demographics
NPI:1922546134
Name:RIEDEL, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:RIEDEL
Suffix:
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 1:1630 OCONTO DR
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-3050
Mailing Address - Country:US
Mailing Address - Phone:608-843-3194
Mailing Address - Fax:
Practice Address - Street 1:1630 OCONTO DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-3050
Practice Address - Country:US
Practice Address - Phone:608-843-3194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer