Provider Demographics
NPI:1265203202
Name:RIDGELL, MICHAEL K'VON
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:K'VON
Last Name:RIDGELL
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 1:4 PAR LN
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-8127
Mailing Address - Country:US
Mailing Address - Phone:870-718-8669
Mailing Address - Fax:870-718-8693
Practice Address - Street 1:543 STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4122
Practice Address - Country:US
Practice Address - Phone:318-673-9901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator