Healthcare Provider Details

I. General information

NPI: 1043371610
Provider Name (Legal Business Name): DARYL LEE RIDGEWAY DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 MAIN PLAZA DR
WENTZVILLE MO
63385-1170
US

IV. Provider business mailing address

1023 MAIN PLAZA DR
WENTZVILLE MO
63385-1170
US

V. Phone/Fax

Practice location:
  • Phone: 636-639-8944
  • Fax:
Mailing address:
  • Phone: 636-639-8944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number006613
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: