Healthcare Provider Details

I. General information

NPI: 1922410786
Provider Name (Legal Business Name): COREY M RIDLEY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 BATES ST SUITE 201
LEWISTON ME
04240-7637
US

IV. Provider business mailing address

266 PARIS RD
HEBRON ME
04238-3414
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-8465
  • Fax:
Mailing address:
  • Phone: 207-212-2185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT203
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: