Provider Demographics
NPI:1053603449
Name:RIDDLE, JODI (LMP)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 POPPY HILLS LN
Mailing Address - Street 2:SUITE 936
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-6554
Mailing Address - Country:US
Mailing Address - Phone:509-315-5561
Mailing Address - Fax:509-315-8354
Practice Address - Street 1:6810 POPPY HILLS LN
Practice Address - Street 2:SUITE 936
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-6554
Practice Address - Country:US
Practice Address - Phone:509-315-5561
Practice Address - Fax:509-315-8354
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5562225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist