Provider Demographics
NPI:1932235165
Name:RIDDLE, BRENT ALAN (MED, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:ALAN
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:MED, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH GRAFTON
Mailing Address - State:MA
Mailing Address - Zip Code:01536-1238
Mailing Address - Country:US
Mailing Address - Phone:508-839-0089
Mailing Address - Fax:
Practice Address - Street 1:24 WILLIAMS RD
Practice Address - Street 2:
Practice Address - City:NORTH GRAFTON
Practice Address - State:MA
Practice Address - Zip Code:01536-1238
Practice Address - Country:US
Practice Address - Phone:508-839-0089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer