Healthcare Provider Details

I. General information

NPI: 1023753704
Provider Name (Legal Business Name): MIX-RIDDLE CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6381 S CHALKVILLE RD
TRUSSVILLE AL
35173-6304
US

IV. Provider business mailing address

6381 S CHALKVILLE RD
TRUSSVILLE AL
35173-6304
US

V. Phone/Fax

Practice location:
  • Phone: 205-661-6600
  • Fax: 205-661-6601
Mailing address:
  • Phone: 205-661-6600
  • Fax: 205-661-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER GILMER RIDDLE
Title or Position: OWNER
Credential: DC
Phone: 205-907-5259