MEDICARE: KEVIN RIDAD

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1629658893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN RIDAD

Provider Business Mailing Address
First Line	:	3336 LEXINGTON DR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-6636
Country	:	US
Telephone Number	:	903-253-6445
Fax Number	:

Provider Business Practice Location Address
First Line	:	4882 HIGHTECH DR
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-2613
Country	:	US
Telephone Number	:	903-300-0234
Fax Number	:

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

Provider Enumeration Date	:	04/12/2021
Last Update Date	:	04/12/2021

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Directions to “ KEVIN RIDAD ” Practice Location

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