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General NPI Number Information
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NPI Number | 1053506097
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Entity Type | Organization
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Legal Business Name | DARYL RIDGEWAY DC LLC
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Dates
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Enumeration Date | 09/12/2007
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Last Update Date | 09/12/2007
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Provider Practice Location Address
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Address Line | 1023 MAIN PLAZA DR
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City | WENTZVILLE
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State | MO
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Zip | 63385-1170
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Country | US
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Telephone | 636-639-8944
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Fax |
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Provider Business Mailing Address
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Address Line | 1023 MAIN PLAZA DR
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City | WENTZVILLE
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State | MO
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Zip | 63385-1170
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Country | US
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Telephone | 636-639-8944
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | DR. DARYL LEE RIDGEWAY
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Credential | DC
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Telephone | 636-639-8944
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 006613
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License Number State | MO
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