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General NPI Number Information
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NPI Number | 1134658107
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Entity Type | Individual
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Provider Name | CLIFFORD FRANCIS RIDEOUT III PTA
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Gender | Male
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Dates
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Enumeration Date | 06/05/2017
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Last Update Date | 08/21/2020
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Provider Practice Location Address
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Address Line | 11974 EDGEHILL TERRACE RD
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City | PRINCESS ANNE
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State | MD
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Zip | 21853-2105
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Country | US
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Telephone | 401-651-0021
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Fax |
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Provider Business Mailing Address
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Address Line | 86 MAPLEWOOD AVE
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City | GLOUCESTER
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State | MA
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Zip | 01930-2732
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Country | US
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Telephone | 978-578-2506
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 7845
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | A4671
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License Number State | MD
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