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General NPI Number Information
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NPI Number | 1104169648
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Entity Type | Individual
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Provider Name | DEMARCUS ANTON RIDEOUT
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Gender | Male
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Dates
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Enumeration Date | 04/03/2013
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Last Update Date | 04/03/2013
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Provider Practice Location Address
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Address Line | 1119 HIGHWAY 13 S
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City | COLUMBIA
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State | MS
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Zip | 39429-8226
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Country | US
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Telephone | 601-441-7434
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Fax |
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Provider Business Mailing Address
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Address Line | 1119 HIGHWAY 13 S
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City | COLUMBIA
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State | MS
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Zip | 39429-8226
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Country | US
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Telephone | 601-441-7434
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385H00000X
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Taxonomy Name | Respite Care
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License Number |
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License Number State |
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