Provider Demographics
NPI:1134238876
Name:RIDER, RANDY (PT, CHT)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:RIDER
Suffix:
Gender:M
Credentials:PT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 SADDLE HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CROZET
Mailing Address - State:VA
Mailing Address - Zip Code:22932-2526
Mailing Address - Country:US
Mailing Address - Phone:434-823-5114
Mailing Address - Fax:
Practice Address - Street 1:5690 THREE NOTCHD RD
Practice Address - Street 2:SUITE 107
Practice Address - City:CROZET
Practice Address - State:VA
Practice Address - Zip Code:22932-3172
Practice Address - Country:US
Practice Address - Phone:434-823-7628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2010-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305203646OtherLICENSE #