Provider Demographics
NPI:1366536609
Name:RIDDLE, CHARLES GUY (DPT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:GUY
Last Name:RIDDLE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3140 W MILANO DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7290
Mailing Address - Country:US
Mailing Address - Phone:208-895-0022
Mailing Address - Fax:208-898-9308
Practice Address - Street 1:1626 S WELLS AVE STE 105
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4528
Practice Address - Country:US
Practice Address - Phone:208-789-0200
Practice Address - Fax:208-288-2784
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT-1978174400000X
IDPT-1978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist