Provider Demographics
NPI:1043867641
Name:RIDER, JOHN STEPHEN (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STEPHEN
Last Name:RIDER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5833 OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1163
Mailing Address - Country:US
Mailing Address - Phone:269-344-4057
Mailing Address - Fax:
Practice Address - Street 1:5833 OAKLAND DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1163
Practice Address - Country:US
Practice Address - Phone:269-344-4057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010749111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor