Healthcare Provider Details

I. General information

NPI: 1538580717
Provider Name (Legal Business Name): LISA P RIDER MA, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2013
Last Update Date: 12/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 BRADFORD TER
WEST CHESTER PA
19382-1818
US

IV. Provider business mailing address

725 BRADFORD TER
WEST CHESTER PA
19382-1818
US

V. Phone/Fax

Practice location:
  • Phone: 610-918-9388
  • Fax:
Mailing address:
  • Phone: 610-918-9388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberDN002247
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: