Basic Information
| Provider Information | |||||||||
| NPI: | 1194347526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDDLE | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | IAN | ||||||||
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| NameSuffix: | SR. | ||||||||
| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 MEADOWLARK CT | ||||||||
| Address2: | |||||||||
| City: | LONGWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327503142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545897217 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 W BROADWAY ST STE 214 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327659262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073595693 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2020 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.