Provider Demographics
NPI:1144042540
Name:RIDER, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:RIDER
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37303 CAMELLIA LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-2019
Mailing Address - Country:US
Mailing Address - Phone:734-645-9243
Mailing Address - Fax:
Practice Address - Street 1:37303 CAMELLIA LN
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-2019
Practice Address - Country:US
Practice Address - Phone:734-645-9243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIR360792098308343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)