Provider Demographics
NPI:1104402395
Name:RIDER, REGINA
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:RIDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1489 DOGTOWN RD LOT 3
Mailing Address - Street 2:
Mailing Address - City:REEDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26547-9797
Mailing Address - Country:US
Mailing Address - Phone:304-441-1969
Mailing Address - Fax:
Practice Address - Street 1:1489 DOGTOWN RD LOT 3
Practice Address - Street 2:
Practice Address - City:REEDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26547-9797
Practice Address - Country:US
Practice Address - Phone:304-441-1969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker