Healthcare Provider Details

I. General information

NPI: 1053506097
Provider Name (Legal Business Name): DARYL RIDGEWAY DC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 09/12/2007
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: DR. DARYL LEE RIDGEWAY
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 636-639-8944