MEDICARE: STACI W RIDDLING PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT21373	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881688588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACI W RIDDLING PT

Provider Business Mailing Address
First Line	:	PO BOX 8847
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32006-0019
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	534 S 5TH ST # A
Second Line	:
City	:	MACCLENNY
State	:	FL
Zip	:	32063
Country	:	US
Telephone Number	:	904-259-1649
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	05/31/2018

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