Healthcare Provider Details

I. General information

NPI: 1124557798
Provider Name (Legal Business Name): EMILY KAY RIDEOUT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10217 CORREE COVE DR
EMERALD ISLE NC
28594-2133
US

IV. Provider business mailing address

10217 CORREE COVE DR
EMERALD ISLE NC
28594-2133
US

V. Phone/Fax

Practice location:
  • Phone: 910-545-2076
  • Fax:
Mailing address:
  • Phone: 910-545-2076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000028725
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: