Individual
RUSSELL JENNINGS RIDER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
IDC
Contact information
Practice address
159 TROUT AVE, GROTON, CT 06340
(860) 694-6464
Mailing address
140 CHERRY CIR, GROTON, CT 06340-3157
(860) 617-0344
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
—
—
Other
Enumeration date
01/13/2020
Last updated
01/13/2020
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