Provider Demographics
NPI:1285402776
Name:GERIDEAU, JOHN JULIUS III (LMT, MLD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JULIUS
Last Name:GERIDEAU
Suffix:III
Gender:M
Credentials:LMT, MLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 DAVIS TER NW
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-4036
Mailing Address - Country:US
Mailing Address - Phone:877-462-1827
Mailing Address - Fax:
Practice Address - Street 1:151 WATERLOO ST SW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3756
Practice Address - Country:US
Practice Address - Phone:877-462-1827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9586225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist