Provider Demographics
NPI:1316501976
Name:RIDDICK, REGINALD
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:RIDDICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 LANCER DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23701-2144
Mailing Address - Country:US
Mailing Address - Phone:757-292-7507
Mailing Address - Fax:
Practice Address - Street 1:611 LANCER DR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701-2144
Practice Address - Country:US
Practice Address - Phone:757-292-7507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)