| Doctor Name: | MR. CHARLES GUY RIDDLE |
| NPI Number: | 1366536609 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | DPT |
| License Number: | RPT-1978 |
| Business Practice Address: | 3140 W Milano Dr Suite 100 Meridian, ID - 836467290 |
| Business Phone Number: | 2088950022 |
| Business Fax Number: | 2088989308 |
| Mailing Address: | 3140 W Milano Dr, Suite 100 MERIDIAN |
| State: | ID |
| Postal Code: | 836467290 |
| Phone Number: | 2088950022 |
| Fax Number: | 2088989308 |
| NPI Enumeration Date: | 10/03/2006 |
| NPI Last Update Date: | 02/05/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | RPT-1978 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | ID |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |