Provider Demographics
NPI:1548968092
Name:RIDDER, GRANT THOMAS
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:THOMAS
Last Name:RIDDER
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 1:1625 W SNOWSHOE DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-1695
Mailing Address - Country:US
Mailing Address - Phone:402-840-2212
Mailing Address - Fax:
Practice Address - Street 1:1625 W SNOWSHOE DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-1695
Practice Address - Country:US
Practice Address - Phone:402-840-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer