Healthcare Provider Details

I. General information

NPI: 1518245158
Provider Name (Legal Business Name): RENEE ANNE RIDER LGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DEPT OF VETERAN AFFAIRS GENOMIC MEDICINE 500 FOOTHILL DRIVE (151Z)
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

DEPT OF VETERAN AFFAIRS GENOMIC MEDICINE 500 FOOTHILL DRIVE (151Z)
SALT LAKE CITY UT
84148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 801-582-1565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number8057722-3602
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: