Healthcare Provider Details

I. General information

NPI: 1053374595
Provider Name (Legal Business Name): SAMANTHA A RIDER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA A TUPPER

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 W SALE RD # F2
LAKE CHARLES LA
70605-2400
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-310-3670
  • Fax: 337-421-1408
Mailing address:
  • Phone: 337-312-8258
  • Fax: 337-312-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1378
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: