Healthcare Provider Details

I. General information

NPI: 1790558021
Provider Name (Legal Business Name): KA'DEEM RIDDICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 MARKET ST
SUFFOLK VA
23434-5236
US

IV. Provider business mailing address

416 MARKET ST
SUFFOLK VA
23434-5236
US

V. Phone/Fax

Practice location:
  • Phone: 757-809-1409
  • Fax: 757-809-0107
Mailing address:
  • Phone: 757-809-1409
  • Fax: 757-809-0107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: