Provider Demographics
NPI:1568656247
Name:RIDGES, BRADLEY QUINTEN (MT)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:QUINTEN
Last Name:RIDGES
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-3314
Mailing Address - Country:US
Mailing Address - Phone:909-913-3591
Mailing Address - Fax:
Practice Address - Street 1:1405 N WILLOW AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-3314
Practice Address - Country:US
Practice Address - Phone:909-913-3591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist