Provider Demographics
NPI:1154545887
Name:RIESENBERG, JOHN J (ATC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:J
Last Name:RIESENBERG
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CRANSTON DR
Mailing Address - Street 2:
Mailing Address - City:CHESNEE
Mailing Address - State:SC
Mailing Address - Zip Code:29323-9068
Mailing Address - Country:US
Mailing Address - Phone:864-541-8565
Mailing Address - Fax:
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303
Practice Address - Country:US
Practice Address - Phone:864-560-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0705021702255A2300X
SC8432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC070502170OtherNATA CERTIFICATION
SC843OtherDHEC