Healthcare Provider Details

I. General information

NPI: 1114475696
Provider Name (Legal Business Name): ADAM RIDDLE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 CHANNEL RD STE 102
LAKE WYLIE SC
29710-6101
US

IV. Provider business mailing address

1311 MAMARONECK AVE STE 140
WHITE PLAINS NY
10605-5224
US

V. Phone/Fax

Practice location:
  • Phone: 803-746-7800
  • Fax: 803-746-7807
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8610
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: