MEDICARE: DR. MARY RIDGE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	X008106	NY

General Provider Information

NPI Number	:	1013000835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY RIDGE D.C.

Provider Business Mailing Address
First Line	:	1881 E MAIN ST
Second Line	:
City	:	MOHEGAN LAKE
State	:	NY
Zip	:	10547-1249
Country	:	US
Telephone Number	:	914-528-8889
Fax Number	:

Provider Business Practice Location Address
First Line	:	1881 E MAIN ST
Second Line	:
City	:	MOHEGAN LAKE
State	:	NY
Zip	:	10547-1249
Country	:	US
Telephone Number	:	914-528-8889
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	01/20/2011

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