Provider Demographics
NPI:1306349527
Name:RIDER, DYLLN THANE (DC)
Entity type:Individual
Prefix:
First Name:DYLLN
Middle Name:THANE
Last Name:RIDER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 ALDER AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534-9133
Mailing Address - Country:US
Mailing Address - Phone:970-578-0082
Mailing Address - Fax:970-703-8151
Practice Address - Street 1:39 S PARISH AVE UNIT 120
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-7855
Practice Address - Country:US
Practice Address - Phone:307-359-2142
Practice Address - Fax:970-703-8151
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0007783111NR0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO853782542Other1306349527