Provider Demographics
NPI:1174337687
Name:RIDER, MIMI KRISTINA MARINA (DPT)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:KRISTINA MARINA
Last Name:RIDER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2650
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-8607
Mailing Address - Country:US
Mailing Address - Phone:972-724-2400
Mailing Address - Fax:972-724-2495
Practice Address - Street 1:8608 PRESTON RD STE 110
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3317
Practice Address - Country:US
Practice Address - Phone:214-432-5862
Practice Address - Fax:214-431-4305
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1405007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist