Provider Demographics
NPI:1730554783
Name:PRIDGEN, ROBERT (MT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:PRIDGEN
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 1:1325 S COLORADO BLVD
Mailing Address - Street 2:#B16
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80222-3303
Mailing Address - Country:US
Mailing Address - Phone:706-248-4542
Mailing Address - Fax:
Practice Address - Street 1:1325 S COLORADO BLVD
Practice Address - Street 2:#B16
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-3303
Practice Address - Country:US
Practice Address - Phone:303-756-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0015481225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist