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NPI Code Detail

MEDICARE: MR. MARIO P. RIDAD

MEDICARE: MR. MARIO P. 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
1225200000XPhysical Therapy Assistant2052710TX

General Provider Information

NPI Number : 1972755072
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MARIO P. RIDAD
Provider Business Mailing Address
First Line : 3336 LEXINGTON DR
Second Line :
City : TYLER
State : TX
Zip : 75701-6636
Country : US
Telephone Number : 903-566-1233
Fax Number :
Provider Business Practice Location Address
First Line : 3301 W PARK ROW BLVD
Second Line :
City : CORSICANA
State : TX
Zip : 75110-4846
Country : US
Telephone Number : 903-874-5238
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/21/2008
Last Update Date : 10/21/2008

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