Healthcare Provider Details

I. General information

NPI: 1124420377
Provider Name (Legal Business Name): MR. SELMMAN RICARDO PADRIDIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E 9TH ST BOX #12
FORT STEWART GA
31314-5036
US

IV. Provider business mailing address

1283 SE 7TH CT
DEERFIELD BEACH FL
33441-5868
US

V. Phone/Fax

Practice location:
  • Phone: 912-435-6081
  • Fax:
Mailing address:
  • Phone: 754-214-9122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number25468079
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: