Provider Demographics
NPI:1912592643
Name:RIDENOUR, KIRK A (LAT, ATC, NASM-CES)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:A
Last Name:RIDENOUR
Suffix:
Gender:M
Credentials:LAT, ATC, NASM-CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 PINE FOREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-5981
Mailing Address - Country:US
Mailing Address - Phone:419-792-9412
Mailing Address - Fax:
Practice Address - Street 1:201 JORDANVILLE RD
Practice Address - Street 2:
Practice Address - City:AYNOR
Practice Address - State:SC
Practice Address - Zip Code:29511-3601
Practice Address - Country:US
Practice Address - Phone:843-488-7109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20000369342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer