Provider Demographics
NPI:1336258987
Name:RIEDEL, KEVIN (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:RIEDEL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 INDUSTRIAL CIR D
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6560
Mailing Address - Country:US
Mailing Address - Phone:303-682-2440
Mailing Address - Fax:303-682-0229
Practice Address - Street 1:1860 INDUSTRIAL CIR STE D
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6560
Practice Address - Country:US
Practice Address - Phone:303-682-2440
Practice Address - Fax:303-682-0229
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO7387OtherLICENSE #